Perforated Appendicitis In Children Research Articles

Perforated Appendicitis in Children: Management, Microbiology, and Antibiotic Stewardship.

Although appendicitis has been described for more than 300 years, its optimal management remains a topic of active investigation. Acute appendicitis is the most common cause of peritonitis in children, and rates of perforated appendicitis are much higher in children than in adults. Increased risk for perforated appendicitis in children is related to a delay in diagnosis due to age, size, access to care, and more. Surgical options include immediate appendectomy versus nonoperative management with intravenous antibiotics ± a drainage procedure, with a subsequent interval appendectomy. Microbiota of perforated appendicitis in children most often includes Escherichia coli, Bacteroides fragilis, Streptococcus, and more. Even though the most common organisms are known, there is a large variety of practice when it comes to postoperative antibiotic management in these patients. Studies discuss the benefits of mono- versus dual or triple therapy without a particular consensus regarding what to use. This is reflected across differing practices at various institutions. In this review, we aim to explore the implications of perforated appendicitis in pediatrics, common organisms seen, antibiotic regimen coverage, and the implications of variations of practice. Resistance to commonly used broad-spectrum antibiotics is evolving, therefore minimization of care variability is needed for improved patient outcomes and proper antibiotic stewardship.

The impact of COVID-19 on racial and ethnic disparities in presentation with perforated appendicitis in children: A retrospective cohort study

BackgroundChildren from racial and ethnic minority groups have higher prevalence of perforated appendicitis, and the COVID-19 pandemic worsened racial and ethnic health-related disparities. We hypothesized that the incidence of perforated appendicitis worsened for children from racial and ethnic minorities during the COVID-19 pandemic. MethodsWe performed a retrospective cohort study of the Pediatric Health Information System for children ages 2-18y undergoing appendectomy pre-pandemic (3/19/2019–3/18/2020) and intra-pandemic (3/19/2020–3/30/2021). The primary outcome was presentation with perforated appendicitis. Multivariable logistic regression with mixed effects estimated the likelihood of presentation with perforated appendicitis. Covariates included race, ethnicity, pandemic status, Child Opportunity Index, gender, insurance, age, and hospital region. ResultsOverall, 33,727 children underwent appendectomy: 16,048 (47.6 %) were Non-Hispanic White, 12,709 (37.7 %) were Hispanic, 2261 (6.7 %) were Non-Hispanic Black, 960 (2.8 %) were Asian, and 1749 (5.2 %) Other. Overall perforated appendicitis rates were unchanged during the pandemic (37.4 % intra-pandemic, 36.4 % pre-pandemic, p = 0.06). Hispanic children were more likely to present with perforated appendicitis intra-pandemic versus pre-pandemic (OR 1.18, 95%CI: 1.07, 1.13). Hispanic children had higher odds of perforated appendicitis versus Non-Hispanic White children pre-pandemic (OR 1.10, 95%CI: 1.00, 1.20) which increased intra-pandemic (OR 1.19, 95%CI: 1.09, 1.30). Publicly-insured children had increased odds of perforated appendicitis intra-pandemic versus pre-pandemic (OR 1.14, 95%CI: 1.03, 1.25), and had increased odds of perforated appendicitis versus privately-insured children (intra-pandemic OR 1.26, 95%CI: 1.16, 1.36; pre-pandemic OR 1.12, 95%CI: 1.04, 1.22). ConclusionsDuring the COVID-19 pandemic, Hispanic and publicly-insured children were more likely to present with perforated appendicitis, suggesting that the pandemic exacerbated existing disparities in healthcare for children with appendicitis. Key messageWe found that Hispanic children and children with public insurance were more likely to present with perforated appendicitis during the COVID-19 pandemic. Public health efforts aimed at ameliorating racial and ethnic disparities created during the COVID-19 pandemic should consider increasing healthcare access for Hispanic children to address bias, racism, and systemic barriers that may prevent families from seeking care.

Hyperfibrinogenemia and hyponatremia as predictors of perforated appendicitis in children: A retrospective cohort study

The aim of this study was to investigate the predictive value of hyperfibrinogenemia and hyponatremia for perforated appendicitis in children. A retrospective review of 521 pediatric patients (≤ 15years) with acute appendicitis confirmed by histopathology from January 2017 to December 2020 was performed. Patients were divided in two groups, those with non-perforated (n = 379; 73%) and perforated appendicitis (n = 142; 27%). The serum values of sodium and fibrinogen were taken before surgery. We performed the receiver operating characteristic analysis for the two biochemical markers. The sensitivity, specificity, positive and negative predictive values for perforated appendicitis in the presence of hyponatremia and hyperfibrinogenemia were calculated. Hyperfibrinogenemia (≥ 4.0g/L) was found in 58.45% of perforated appendicitis and 104 of 142 (73.34%) children with perforated appendicitis had hyponatremia (≤ 135mmol/L). The perforated appendicitis group had a higher mean fibrinogen concentration (P = 0.001). There was a statistically significant difference in mean serum sodium levels between the perforated appendicitis and non-perforated appendicitis groups (P = 0.016). Receiver operating characteristic curve analysis for fibrinogen, sodium and combination of the both markers shown the combination had the largest area under the curve in identifying children with perforated acute appendicitis (0.858) (95% CI, 0.82-0.90) compared with fibrinogen (0.815) (95% CI, 0.77-0.86) and sodium 0.818 (95% CI, 0.78-0.86) alone. Furthermore, the combination of both markers had the best positive and negative predictive value for appendix perforation compared to fibrinogen and sodium. Hyponatremia and/or hyperfibrinogenemia are excellent markers for predicting perforated appendicitis in children. We propose that plasma sodium and/or fibrinogen concentrations be utilized as a supplementary to guide individual treatment decisions in children with appendicitis, such as surgery timing and nonoperative management options.

Sodium Levels and Leukocyte Levels as Predictor Factors in Cases of Pediatric Perforated Appendicitis

Acute appendicitis is a surgical emergency that is often found in children with higher perforation rates at a younger age. Several examinations have been put forward as predictors of the incidence of appendix perforation. The purpose of this study was to determine the role of sodium and leukocytes as predictors of perforated appendicitis in children at RSUP Dr. M. Djamil, Padang. This type of research is analytical with a cross-sectional study design. The study was conducted from August to October 2022 at RSUP Dr. M. Djamil Padang. The sample was taken by consecutive sampling with criteria aged 0-18 years and diagnosed with acute appendicitis at RSUP Dr. M. Djamil. In this study, a sample of 112 people with perforation occurred in 67 samples (60%). In the perforation group, most patients (55%) aged 6-11 years were male (67%), had hyponatremia laboratory results (91%) and leukocytosis laboratory results (86.5%) and underwent laparotomy procedures (57.2%). From the SPSS results, a significant difference was obtained between the incidence of hyponatremia in perforated and non-perforated appendicitis with a p-value of <0.001. The limit of the predictive value of sodium is ?134.5 mmol / L. Leukocytes were also found to be associated with perforated appendicitis with a p-value of <0.001 The limit of the predictive value of leukocytes is ? 14,025 cells / mm3. There was a significant association between sodium and leukocyte levels and perforation incidence with predictive value limits of ?134.5 mmol/L and ? 14,025 cells/mm3, respectively.

Sodium Levels as a Predicting Factor for the Occurrence of Perforated Appendicitis in Children at Dr. M. Djamil General Hospital Padang

Background: Perforation of the appendix can lead to life-threatening complications. Early identification of a perforation before surgery has important clinical implications. Hyponatremia was previously proposed as a marker to differentiate between perforated and non-perforated acute appendicitis. This study aims to determine the role of sodium levels as a predictive factor in the incidence of perforated appendicitis in children at Dr. M. Djamil General Hospital Padang.
 Methods: This research is an analytic observational study with a cross-sectional design. The research took place from March to May 2022 at Dr. M. Djamil General Hospital Padang. Samples were taken by consecutive sampling with criteria aged 0-18 years and diagnosed with acute appendicitis at Dr. M. Djamil General Hospital Padang.
 Results: A total of 112 samples with most of the patients (52.7%) aged 6-11 years and found a greater proportion of men (57.1%). Most of the patients underwent laparotomy procedures (57.2%). Hyponatremia was found in 58% of patients. Perforation occurred in most (59.8%) patients. SPSS results showed a significant difference between the incidence of hyponatremia in perforated and non-perforated appendicitis with a p-value <0.001.
 Conclusion: There is a significant relationship between sodium levels and the incidence of perforation, where the lower the sodium level, the higher the incidence of perforation.

A shortened course of Amoxicillin/Clavulanate is the preferred antibiotic treatment after surgery for perforated appendicitis in children

Background/purposeDespite evidence supporting short course outpatient antibiotic treatment following appendectomy for perforated appendicitis, evidence of real-world implementation and consensus for antibiotic choice is lacking. We therefore aimed to compare outpatient antibiotic treatment regimens in a national cohort. MethodsWe identified children who underwent surgery for perforated appendicitis between 2010 and 2018 using the PearlDiver database and compared 45-day disease-specific readmission between children who received shortened (5–8 days) versus prolonged (10–14 day) total antibiotic courses (inpatient intravenous and/or oral) completed with outpatient Amoxicillin/Clavulanate versus Ciprofloxacin/Metronidazole, and compared antibiotic type (5–14 days) to each other. Results4916 children were identified, 2001 (90.0%) treated with Amoxicillin/Clavulanate (5–14 days), 381 (19.0%) with shortened (5–8 days), 1464 (73.2%) with prolonged (10–14 days) courses. 222 (10.0%) were treated with Ciprofloxacin/Metronidazole, 44 (19.8%) with shortened, 174 (78.4%) with prolonged courses. Freedom from readmission was not different between prolonged and shortened course whether they received Amoxicillin/Clavulanate (adjusted hazard ratio [AHR] 1.54, 95%CI 0.95–2.5) or Ciprofloxacin/Metronidazole (AHR 3.49, 95%CI 0.45–27.3). Antibiotic type did not affect readmission rate (Amoxicillin/Clavulanate versus Ciprofloxacin/Metronidazole, AHR 1.21, 95%CI 0.71–2.05). ConclusionProlonged antibiotic regimens are routinely prescribed despite evidence suggesting shorter courses and antibiotic choice are not associated with greater treatment failure. As it is better tolerated, we recommend a shortened course of Amoxicillin/Clavulanate for oral management of perforated appendicitis. Study designRetrospective. Level of evidenceLevel III.

Postoperative hyperlipasemia in perforated appendicitis in children.

The objective of this study was to assess the hyperlipasemia cases detected in the postoperative period of perforated appendicitis. A retrospective analysis of the perforated appendicitis cases occurred in our institution over a 7-year period (2013-2019) was carried out. Only cases where preoperative and postoperative serum lipase levels were available were included. The variables collected were statistically assessed by means of a descriptive, univariate analysis. A total of 88 patients were studied. They were divided into 3 groups according to postoperative lipase levels - 57 were allocated to Group 1 (lipase: 70-194.0 U/L, normal range), 20 were allocated to Group 2 (lipase: 195-582 U/L), and 11 were allocated to Group 3 (lipase: >582 U/L, which triples normal levels). Statistically significant differences were found in the following variables: sex, postoperative abscess, postoperative subocclusion/intestinal occlusion, preoperative lipase levels, days of parenteral nutrition, days of ICU stay, and days of hospital stay. Postoperative lipase had a moderate correlation with preoperative lipase, and none of the cases met acute pancreatitis diagnostic criteria. Hyperlipasemia in the postoperative period of perforated appendicitis is not associated with developing clinical pancreatitis, but it is associated with worse progression in terms of increased complications, such as subocclusion/intestinal occlusion and intra-abdominal abscess, and longer ICU stay, hospital stay, and parenteral nutrition. There is a moderate correlation between preoperative and postoperative lipase, which means they could both prove useful as prognostic markers.

Neutrophilic-lymphocytes and platelet-lymphocytes ratios as predictors for acute perforated appendicitis in children.

This study aimed to evaluate the neutrophil-lymphocyte (NLR) and platelet-lymphocyte (PLR) ratios as markers of perforated appendicitis. We conducted a cross-sectional analytical study. We performed a secondary analysis of a population of pediatric patients who underwent appendectomy between 2017 and 2019 at the Regional Hospital of Ayacucho, Peru. Logistic regression models were used to analyze markers (NLR and PLR) and perforated appendicitis. Later, ROC (receiver operating characteristic) curves were constructed, and sensitivity, specificity, and likelihood ratios were estimated. We identified 31% of perforated appendicitis in 203 patients. A significant association was observed between perforated appendicitis and NLR values > 10.4 (odds ratio [OR]: 2.53; 95% confidence interval [95% CI]: 1.27-5.05) and PLR > 284 (OR: 2.11; 95% CI: 1.09-4.08) in the adjusted analysis. For these models, the areas under the curve were 0.74 (95% CI: 0.67 - 0.81) for both variables. With a cut-off point of 30% probability of perforated appendicitis, we observed sensitivity of 77.78% for both NLR and PLR (likelihood ratio +2.37 and +2.14, respectively), and specificity of 67.14% and 63.57% for NLR and PLR (likelihood ratio -0.33), respectively. Our study showed a significant association between NLR and PLR and acute perforated appendicitis. Future studies should validate the model and corroborate the performance of these markers.

The predictors of perforated appendicitis in the pediatric emergency department: A retrospective observational cohort study.

Appendiceal perforation has significant effects on perioperative morbidity and postoperative outcome. The present study aimed to identify possible predictive factors associated with perforated appendicitis (PA) in children at admission in the emergency department (ED). In this retrospective observational cohort study, consecutive medical records of children <18 years old with surgically and histopathologically confirmed acute appendicitis (AA) over three years (2013-2015) were analyzed. Patients were divided into two groups: PA and non-perforated appendicitis (NPA). The differences between the two groups and potential predictors of PA were explored using univariate and multivariate analyses. During the study period, 295 patients underwent an appendectomy and had confirmatory AA diagnoses. Ninety-two patients had a PA (31.2%). In the univariate analysis, male gender, vomiting, diarrhea, fever, elevated white blood cell count (WBC) levels, and high C-reactive protein (CRP) were identified as predictors of PA. In the multivariate analysis, male gender (odds ratio [OR]: 3.133; 95% confidence interval [CI]: 1.610-6.096); vomiting (OR: 2.346; 95% CI: 1.141-4.822); diarrhea (OR: 4.549; 95% CI: 1.850-11.181); fever (OR: 3.429; 95% CI: 1.765-6.663); elevated WBC (OR: 2.962; 95% CI: 1.491-5.884) and elevated CRP (OR: 3.061; 95% CI: 1.267-7.396) were variables that predicted the PA in children. Our data indicate that several clinical and biochemical parameters can reliably distinguish between pediatric PA and NPA at admission in the emergency department.

Hyperbilirubinemia as an Indicator of Perforated Acute Appendicitis in Pediatric Population: A Prospective Study.

Background: This prospective cohort study aimed to investigate the association of hyperbilirubinemia with perforated appendicitis in the pediatric population. Patients and Methods: A total of 284 children in whom the diagnosis of acute appendicitis was established were included in this study. The patients were allocated in study groups in regard to operative findings. The first study group included patients who had perforated appendicitis (n = 64; 22.5%) whereas the patients in the second group had simple appendicitis (n = 220; 77.5%). Blood samples for serum bilirubin levels and acute inflammatory markers were taken before the patients underwent surgery. The primary outcome of the study was to investigate whether the level of serum bilirubin should be used to distinguish between simple and perforated appendicitis. Results: The median level of serum bilirubin in children with perforated appendicitis was 27 mcmol/L whereas the patients with simple appendicitis had lower median levels of serum bilirubin (10 μmol/L; p < 0.001). An area under the receiver operating characteristic (ROC) curve for total serum bilirubin was 0.876 (95% confidence interval [CI], 0.820-0.929) in the patients who had a perforated appendicitis. An ROC analysis showed the best sensitivity (92%) and specificity (77.3%) for a cutoff value of 15.5 mcmol/L for total serum bilirubin (p < 0.001). Hyperbilirubinemia at admission was found in 35 patients (54.7%) with complicated appendicitis and in 14 patients (6.4%) with non-perforated appendicitis (p < 0.001). The modeling of collected data by multivariable logistic regression identified serum bilirubin concentration (odss ratio [OR] = 1.12; 95% CI, 1.07-1.18; p < 0.001), serum sodium concentration (OR = 0.64; 95% CI, 0.51-0.81; p < 0.001), body temperature (OR = 2.48; 95% CI, 1.05-0.84; p < 0.001), and duration of symptoms (OR = 1.06; 95% CI, 1.02-1.09; p < 0.001) as risk factors for perforated appendicitis. Conclusion: Elevateds level of total serum bilirubin may be useful as an indicator of perforated appendicitis in children. Levels of bilirubin in serum is an inexpensive, simple, and available laboratory marker and should therefore be recommended in the initial evaluation for acute appendicitis in pediatric patients.

Trends in Appendicitis and Perforated Appendicitis Prevalence in Children in the United States, 2001-2015

This sequential, cross-sectional study examines the prevalence of perforated appendicitis in children in the United States in relation to access to health care from 2001 to 2015.

Prophylactic Drain Placement in Childhood Perforated Appendicitis: Does Spillage Matter?

Background: Prophylactic abdominal drains for perforated appendicitis in children have generally been regarded as obsolete because several studies showed inferior results for drain placement in the past. Despite these results, prophylactic abdominal drains for perforated appendicitis remain omnipresent in pediatric surgery especially when gross spillage is observed at the time of appendectomy. Here, we hypothesize that even if accounting for gross intra-abdominal spillage, prophylactic drain placement for perforated appendicitis in children is not beneficial.Patients and Methods: The charts of all children (<18 years) who underwent an appendectomy at our institution from July 2013 to March 2020 were analyzed. The data from 65 patients who presented with perforated appendicitis were included. Patients were grouped according to the amount of intraoperative spillage. Demographics, laboratory data, operative findings, and postoperative outcomes were analyzed.Results: Of all patients, 34 were male, and 31 were female, with a mean age of 10.5 ± 3.7 years. There were no statistically significant differences between the groups for age and sex (p = 0.6985 and p = 0.6222, respectively). Prophylactic drains were placed according to the surgeon's preference in 32 children. There were no statistically significant differences between the groups in the rate of intra-abdominal abscess formation, wound infection, and bowel obstruction, regardless of the amount of spillage encountered during an appendectomy. However, independently of the amount of spillage, the length of hospital stay was longer in the children in which a drain had been placed (p = 0.0041).Conclusion: In our cohort, we could not find a benefit from drain placement even in case of gross spillage at the time of appendectomy. Rather, drain placement was associated with an increase in length of hospital stay.

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.

Oral Antibiotics and Abscess Formation After Appendectomy for Perforated Appendicitis in Children

BackgroundThere is little consensus regarding the use of postoperative antibiotics in the management of perforated appendicitis in children. Patients are commonly discharged with oral antibiotics after a course of intravenous antibiotics; however, recent literature suggests that patients can be safely discharged without any oral antibiotics. To further evaluate this protocol, we conducted a multicenter retrospective preimplementation/postimplementation study comparing rates of abscess formation and rehospitalization between patients discharged with and without oral antibiotics. Materials and MethodsWe reviewed the records of all pediatric patients who underwent appendectomies for perforated appendicitis at NYU Tisch Hospital, Bellevue Hospital, and Hackensack University Medical Center from January 2014 to June 2019. Data pertaining to patient demographics, hospital course, intraoperative appearance of the appendix, antibiotic treatment, abscess formation, and rehospitalization were collected. ResultsA total of 253 patients were included: 162 received oral antibiotics and 91 did not. The median length of antibiotic treatment (oral and intravenous) was 11 (10-14) d for patients on oral antibiotics and 5 (3-6) d for patients without oral antibiotics (P < 0.01). The median leukocyte count at discharge was 9.5 (7.4-10.9) and 8.1 (6.8-10.4) for these groups, respectively (P = 0.02). Postoperative abscesses occurred in 22% of patients receiving oral antibiotics and 15% of patients on no antibiotics (P = 0.25). Rates of rehospitalization for these groups were 10% and 11%, respectively (P = 0.99). ConclusionsChildren who have undergone appendectomy for perforated appendicitis can be safely discharged without oral antibiotics on meeting clinical discharge criteria and white blood cell count normalization.

Evaluation of some cellular biomarker proteins, oxidative stress and clinical indices as results of laparoscopic appendectomy for perforated appendicitis in children

Laparoscopic appendectomy for perforated appendicitis in children has the advantages of quick recovery, little influence of inflammatory and oxidative stress and low infection rate. Altogether 115 children with perforated appendicitis treated in our hospital from June 2018 to August 2019 were selected and divided into two groups according to different treatment methods. Laparoscopic appendectomy was used as the research group (RG) (67 cases) and open appendectomy (48 cases) as the control group (CG). The clinical indexes (operation time, intraoperative blood loss, ambulation time, incision length, postoperative exhaust time and length of stay) of the two groups were observed. The levels of C- reactive protein (CRP), procalcitonin (PCT), interleukin -6 (IL-6) and tumor necrosis factor-α (TNF-α) before and after treatment were detected by enzyme-linked immunosorbent assay (ELISA). The levels of oxidative stress factors (superoxide dismutase (SOD), malondialdehyde (MDA)) and the incidence of postoperative incision infection were observed in the two groups. A visual analogue scale (VAS) score was used to evaluate the postoperative pain in children. Logistic regression analysis was used to analyze the risk factors of postoperative incision infection in children. The improvement degree of clinical indicators in RG was significantly better than that in CG. The expression levels of CRP, PCT, IL-6 and TNF-α in RG were significantly lower than those in CG. The expression levels of SOD and MDA in RG were significantly better than those in CG. The postoperative incision infection rate in RG was significantly lower than that in CG. The postoperative VAS score in RG was significantly lower than that in CG. Logistic regression analysis results showed that the risk of incision infection was increased in children with operation time over 1h, incision length &gt;3cm, high CRP, high PCT, high IL-6, high TNF-α, high SOD and low MDA. Laparoscopic appendectomy for perforated appendicitis in children can effectively reduce intraoperative hemorrhage, postoperative pain, and the damage to the body of children, and can also reduce oxidative stress and inflammatory reaction in children.

Analysis of predictive factors for perforated appendicitis in children.

The aim of this research was to investigate the diagnostic value of objective factors present at admission for identifying predictive markers of perforated appendicitis in children. We performed a retrospective case review of 319 children aged ≤15years who underwent treatment for acute appendicitis at our institution over a 6-year period from January 2011 to December 2016. Univariate and multivariate analyses were performed to identify risk factors for perforation of acute appendicitis in children. In the 6-year period, 319 patients underwent treatment for acute appendicitis, of whom 72 (22.6%) had perforated appendicitis. Multivariate analysis revealed five independent factors predicting perforated appendicitis at admission: longer symptom duration (≥2days), fever (axillary temperature ≥38.0 °C), elevated C-reactive protein level (≥3.46mg/dL), appendiceal fecalith on imaging, and ascites on imaging. Among patients with all five risk factors, 93.3% had perforated appendicitis. None of the patients without any of these factors had a perforated appendicitis. Longer symptom duration (≥2days), fever (axillary temperature ≥38.0 °C), elevated C-reactive protein level, and the presence of appendiceal fecalith and ascites on imaging are independent and objective factors predicting perforated appendicitis at admission. These risk factors have the potential to be helpful as an ancillary index for physicians determining the severity of appendicitis.

Povidone-iodine Irrigation for Pediatric Perforated Appendicitis May Be Protective

A randomized controlled trial was conducted to test the hypothesis that povidone-iodine (PVI) irrigation versus no irrigation (NI) reduces postoperative intra-abdominal abscess (IAA) in children with perforated appendicitis. A 100 patient pilot randomized controlled trial was conducted. Consecutive patients with acute perforated appendicitis were randomized (1:1) to PVI or NI from April 2016 to March 2017 and followed for 1 year. Patients and postoperative providers were blinded to allocation. The primary endpoint was 30-day image-confirmed IAA. Secondary outcomes included initial and total 30-day length of stay (LOS), emergency department (ED) visits, and readmissions. Intention-to-treat analyses were performed to estimate the probability of clinical benefit using Bayesian regression models (an optimistic prior for the primary outcome and neutral priors for secondary outcomes). Frequentist statistics were also used. Baseline characteristics were similar between treatment arms. The PVI arm had 12% postoperative IAA versus 16% in the NI arm (relative risk 0.72, 95% credible interval 0.38-1.23). Bayesian analysis estimates 89% probability that PVI reduces IAA. High probability of benefit was seen in all secondary outcomes for the PVI arm: fewer ED visits and readmissions, and shorter initial and total 30-day LOS. The probability of benefit in reduction of total 30-day LOS in PVI patients was 96% and was significant (P = 0.05) on frequentist analysis. PVI irrigation for perforated appendicitis in children demonstrated a strong probability of reduction in postoperative IAA with a high probability of decreased LOS. With the favorable probability of benefit in all outcomes, this pilot study serves as evidence to continue a definitive trial.

Role of mean platelet volume-to-lymphocyte ratio in the diagnosis of childhood appendicitis

Mean platelet volume - to -lymphocyte ratio (MPVLR) has emerged as a novel parameter of inflammation and thrombosis. The aim was to evaluate whether MPVLR has a role in the diagnosis of childhood appendicitis. Retrospectively reviewed the medical records up to 18 year with suspected acute appendicitis (AA) who underwent appendectomy between January 2016 and December 2017. Based on histopathological evaluation, the patients were classified into normal appendix, and simple and perforated appendicitis. Preoperative mean platelet volume (MPV), platelet distribution width (PDW), MPVLR, platelet-to-lymphocyte ratio (PLR), counts of platelets and white blood cells (WBC), and C-reactive protein (CRP) levels were measured. A total of 219 children with clinically suspected AA who underwent surgical treatment for appendicitis were reviewed, and 100 genderage matched healthy subjects were included. Compared with the controls, the mean levels of MPVLR, PLR, WBC and CRP were significantly higher in the children underwent appendectomy (p <0.001). These values were significantly higher in simple appendicitis than in normal appendices (p<0.01). Compared with simple appendicitis, these levels were significantly higher in the children with perforated appendicitis (p <0.001). The area under curves for MPVLR and PLR were 0.771 and 0.726 in the prediction of appendicitis and 0.693 and 0.722 in the prediction of perforation, respectively. Increased level of MPVLR may be valuable for aiding the diagnosis of pediatric AA. In addition , it can help discriminate simple and perforated appendicitis in children.

Does laparoscopic appendectomy increase the risk of intra-abdominal abscess in children who have perforated appendicitis?

Objective: The aim of this study is to compare the rates of intraabdominal abscesses (IAAs), in laparoscopic appendectomy (LA) and open appendectomy (OA) for perforated appendicitis in children. Methods: A retrospective database search of consecutive cases of children with a diagnosis of perforated appendicitis who underwent OA or LA by the first author or were operated under his supervision diagnosed with appendicitis between 2011 and 2014 and who underwent surgery as treatment was conducted.Results: Seventy-eight patients were included in our study. Forty-two and 36 patients underwent LA and OA, respectively. One case was converted from LA to OA. There was no statistically significant difference at superficial incisional surgical-site infections and IAA between groups but drain placement ratio and length of hospital stay was higher in OA group. Conclusions: The lack of difference in postoperative incidence of IAA supports the idea that LA does not increase the risk of IAA in perforated appendicitis. Although LA for perforated appendicitis in children has been intensely debated, our findings indicate that laparoscopic procedures performed by experienced pediatric surgeons will decrease the risk of complication and conversion to OA. Laparoscopy in children is a safe procedure for perforated, complicated appendicitis.

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

BackgroundManagement 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. MethodsA 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. ResultsIO 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). ConclusionsOur 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 EvidenceIV.