Treatment Of Appendicitis In Children Research Articles

The Advancement of Appendicitis in Children in the Pre-Pandemic and the Pandemic Year.

Background: The COVID-19 pandemic affected the health of millions of people, both directly through infection and indirectly through delayed diagnosis and treatment of non-COVID-19 illnesses. The aim of this study was to check the impact of the COVID-19 pandemic on the diagnosis and treatment of appendicitis in children. Methods: The study was carried out at the Department of Paediatric Surgery of the Marciniak Hospital (Wrocław, Poland) and covered two periods, the pre-pandemic one (P1, 01/03/2019-29/02/2020) and the pandemic one (P2, 01/03/2020-28/02/2021). Results: The number of admissions of patients with suspected appendicitis and observation-only patients decreased during the pandemic (400/289 and 226/160, respectively). Although the number of operated children was similar during both analyzed periods (P1: 174, P2: 160), the rate of surgical interventions was significantly higher during P2 (55.4%) than during P1 (43.5%) (χ2 test: p = 0.00272). The values of the variables quantifying disease progression and severity of inflammation, selected inflammation-related parameters detected by laboratory blood tests, latencies from the onset of symptoms to the admission and from the admission to the operation, and total duration of hospitalization did not differ significantly between the pre-pandemic and pandemic periods. Conclusions: These results show that the COVID-19 pandemic led to more rigorous and careful triage of pediatric patients suspected of acute appendicitis that did not have a negative impact on patient outcomes.

Racial and insurance status disparities in imaging modality among pediatric patients diagnosed with appendicitis

BackgroundStudies have assessed the type of diagnostic imaging used in the treatment of appendicitis in children. Few studies investigated racial/ethnic and insurance disparities in imaging modalities used in pediatric patients diagnosed with appendicitis. Our study seeks to determine whether race/ethnicity and insurance status are associated with imaging modality chosen for pediatric patients diagnosed with appendicitis in the emergency department. MethodsThis was a retrospective cohort study utilizing data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2010 to 2019. We included children <18 years old with a ICD-9-CM and ICD-10-CM diagnosis of appendicitis. Exposures were patient race/ethnicity and insurance status. Outcome of interest was imaging modality. We conducted adjusted survey logistic regression to evaluate the patient characteristics and receipt each of the imaging modalities among those with a diagnosis of appendicitis. ResultsOf 308,140,115 emergency department (ED) visits, 1,126,865 (0.37%) had a diagnosis of appendicitis. Overall, male patients were more likely to receive CAT scan in comparison to female children (OR=2.52, 95% CI= 1.16–5.49). Additionally, Hispanic children who had significantly greater odds of obtaining ultrasound (OR= 4.56, 95% CI=1.09–19.12). Hispanic children were also less likely to receive x-ray (OR= 0.31, 95% CI=0.11–0.89) or computed tomography (CT) scans (OR= 0.23, 95% CI=0.07–0.76). Children diagnosed with appendicitis who had insurance other than private, Medicare, Medicaid, or self-pay were significantly more likely to receive x-ray studies (OR=4.39, 95% CI= 1.23–15.69). Conclusions and global health implicationsThis study demonstrated the presence of racial/ethnic and insurance status disparities in the imaging modality chosen to assist in diagnosing appendicitis in pediatric patients.

Comparison of inflammatory markers in the differentiation of uncomplicated appendicitis and complicated appendicitis

Introduction:&#x0D; Appendicitis is the common emergency surgery performed in the pediatric age group. However, it has been reported in recent studies that some appendicitis cases will benefit from antibiotic treatment and that they can be followed up without surgery. In our study, it was aimed to compare the pre-operative inflammatory markers with the pathology results of the patients who were operated for appendicitis in our clinic and to reveal their success in the distinction between acute appendicitis and complicated appendicitis.&#x0D; Materials and Methods:&#x0D; The data of 98 patients who were operated with a pre-diagnosis of appendicitis in the pediatric surgery clinic of our hospital between 2019 and 2021 were retrospectively analyzed. Acute appendicitis and complicated appendicitis grouping was made according to pathological diagnoses. The inflammatory markers were evaluated.&#x0D; Results:&#x0D; According to the pathological grouping, 51 (56.7%) patients are in the acute appendicitis group. It was observed that only the change in the CRP value in the binary regression evaluation created for the parameters whose difference was significant evaluation increased the complicated appendicitis probability 1.028 times. It was seen that the CRP value of 34.65 was a parameter that could distinguish between acute appendicitis and complicated append with 79.5% sensitivity and 78.4% specificity.&#x0D; Conclusion:&#x0D; The treatment of appendicitis in children is a subject that is still being studied and has many points that have not been clarified. Among the markers that can be used in treatment planning, CRP gives usable results. More detailed and larger series are needed for other markers.

CONservative TReatment of Appendicitis in Children: a randomised controlled feasibility Trial (CONTRACT)

ObjectiveTo establish the feasibility of a multicentre randomised controlled trial to assess the effectiveness and cost-effectiveness of a non-operative treatment pathway compared with appendicectomy in children with uncomplicated acute appendicitis.DesignFeasibility...

Frequency of port-site infection in children undergoing laparoscopic appendectomy for uncomplicated appendicitis

Background: Laparoscopic appendectomy is being practiced throughout the world for the treatment of acute appendicitis in children and adults. The objective of this study was to determine the frequency of port sites infection in children undergoing laparoscopic appendectomy at our institution. Methods: The study was conducted at the Pediatric Surgery Unit of Lady Reading Hospital Peshawar from January 2014 to Jan 2015. All the patients with the diagnosis of acute appendicitis underwent a three-port laparoscopic appendectomy. Port-site infection was noted postoperatively. Results: Total number of patients in this study was 207 including 138 males (66.70%) and 69 (33.3%) females (M:F 2:1). The age ranged from 6 to 14 years, with mean age of 11 years ±2.096. The overall complications occurred in 39 (18.84%) patients. The port-site infection occurred in 33 (16%) patients. Port-site infection involved only the umbilical port sites and was superficial. Port-site infection was managed conservatively without any sequelae. Conclusion: Laparoscopic appendectomy is a safe technique in children with port-site infection rate of 16%. There is no morbidity as all the port-site infections occurred at umbilical port-site were superficial thus managed conservatively.

Enhancing communication, informed consent and recruitment in a paediatric urgent care surgical trial: a qualitative study

BackgroundRecruiting patients to paediatric trials can be challenging, especially in trials that compare markedly different management pathways and are conducted in acute settings. We aimed to enhance informed consent and recruitment in the CONTRACT trial (CONservative TReatment of Appendicitis in Children a randomised controlled Trial; ISRCTN15830435) – a feasibility trial that compared non-operative treatment (antibiotics) versus appendicectomy for uncomplicated acute appendicitis.MethodsQualitative study embedded within CONTRACT and conducted across three UK children’s hospitals. Data were transcribed audio-recordings of 85 CONTRACT recruitment consultations with 58 families; and semi-structured interviews with 35 health professionals and 28 families (34 parents, 14 children) invited to participate in CONTRACT. Data analysis drew on thematic approaches. Throughout CONTRACT, we used findings from the ongoing qualitative analysis to inform bespoke communication training for health professionals recruiting to CONTRACT. Before and after training we also examined qualitative changes in communication during consultations and quantitative changes in recruitment rates.ResultsBespoke communication training focussed on presenting the trial arms in a balanced way, emphasising clinical equipoise, exploring family treatment preferences and managing families’ expectations about the trial’s treatment pathways. Analysis of recruitment consultations indicated that health professionals’ presentation of treatment arms became increasingly balanced following training, (e.g. avoiding imbalanced terminology) and recruitment rose from 38 to 62%. However, they remained reluctant to explore families’ treatment preferences and respond with further information to balance these preferences. Analyses of interviews identified the time constraints of the urgent care setting, concerns about coercion, and reservations about exposing children to conversations about treatment risks as reasons for this reluctance. Interviews with families indicated the importance of clear explanations of trial treatment timings and sensitive communication of treatment allocation for both recruitment and retention.ConclusionsFollowing bespoke training based on the qualitative analyses, health professionals presented CONTRACT to families in clearer and more balanced ways and this was associated with an increase in the recruitment rate. Despite training, health professionals remained reluctant to explore families’ treatment preferences. We provide several recommendations to enhance communication, informed consent, recruitment and retention in future trials in urgent care settings.

Comparative Study of a Single-Incision Laparoscopic and a Conventional Laparoscopic Appendectomy for the Treatment of Acute Appendicitis in Children

Appendicitis is the most common indication for urgent surgery in children. Single-incision laparoscopic surgery (SILS) has further improved surgical outcomes. In this study we compared SILS and conventional in terms of peroperative difficulty and outcomes. A retrospective chart review was performed interesting all patients operated for acute appendicitis in the department of pediatric surgery Hedi Chaker hospital and department of surgery Habib Borguiba hospital between January 2006 and December 2016. Among the total of 181 patients, LA and SILS were performed respectively on 51 (28.2%) and 137 patients (71.8%). In 41.9% of patients of conventional LA it was a complicated appendicitis and in 29.8% of SILS group it was a complicated appendicitis (p=0.22). The mean operative time was 63.7 min for the conventional LA group and 71.79 min for the SILS group, it was not statistically significant (p=0.046). Conversion was made in 13.7% of patients in the conventional LA and in 5.8% in patients with SILS (p=0.14). The median length of hospital stay was for the conventional LA group 3.5 days and for SILS group 2.3 days (p=0.04). The current study found that SILS provided comparable surgical outcomes to conventional LA and did not result in increased postoperative complication rates.

Clinical recovery in children with uncomplicated appendicitis undergoing non-operative treatment: secondary analysis of a prospective cohort study

Non-operative treatment of uncomplicated appendicitis in children is gaining ground. Pending definitive evidence regarding its effectiveness, there is a call to evaluate clinical recovery after non-operative treatment. In this study, we analyzed data collected during initial admission of a multicenter prospective cohort in which children, 7–17 year, were treated non-operatively for uncomplicated appendicitis. During admission clinical parameters (pain and gastro-intestinal symptoms), inflammation parameters and sequential abdominal ultrasound were recorded. In total, 45 children were included, 42(93%) were discharged without the need for appendectomy; median [IQR] pain scores on admission were 5 [4–7], decreasing to 2 [0–3] after 1 day of treatment. Initially, 28/42 (67%) reported nausea and 19/42 (45%) vomiting; after 1 day, this was 3/42 (7%) and 1/42 (2%), respectively. White blood cell count declined from a median [IQR] of 12.9 [10.7–16.7] 10E9/L on admission to 7.0 [5.8–9.9] 10E9/L on day 1. Median [IQR] C-reactive protein levels increased from 27.5 [9–69] mg/L on admission to 48 [22–80] mg/L on day 1, declining to 21.5 [11–42] mg/L on day 2. Follow-up ultrasound showed no signs of complicated appendicitis in any of the patients.Conclusion: Clinical symptoms resolved in most children after 1 day of non-operative treatment. This suggests that non-operative treatment is a viable alternative to appendectomy regarding clinical recovery.Trail registration: NCT01356641What is Known:• Non-operative treatment of uncomplicated appendicitis in children is safe and its use around the world is gaining ground, however high quality evidence from adequately designed randomized trials is still lacking.• Concerns have been raised regarding the potentially prolonged clinical recovery associated with non-operative treatment.What is New:• Most clinical symptoms resolve after 1 day of non-operative treatment in the majority of children.

CONTRACT Study - CONservative TReatment of Appendicitis in Children (feasibility): study protocol for a randomised controlled Trial

BackgroundCurrently, the routine treatment for acute appendicitis in the United Kingdom is an appendicectomy. However, there is increasing scientific interest and research into non-operative treatment of appendicitis in adults and children. While a number of studies have investigated non-operative treatment of appendicitis in adults, this research cannot be applied to the paediatric population. Ultimately, we aim to perform a UK-based multicentre randomised controlled trial (RCT) to test the clinical and cost effectiveness of non-operative treatment of acute uncomplicated appendicitis in children, as compared with appendicectomy. First, we will undertake a feasibility study to assess the feasibility of performing such a trial.Methods/designThe study involves a feasibility RCT with a nested qualitative research to optimise recruitment as well as a health economic substudy. Children (aged 4–15 years inclusive) diagnosed with acute uncomplicated appendicitis that would normally be treated with an appendicectomy are eligible for the RCT. Exclusion criteria include clinical/radiological suspicion of perforated appendicitis, appendix mass or previous non-operative treatment of appendicitis. Participants will be randomised into one of two arms. Participants in the intervention arm are treated with antibiotics and regular clinical assessment to ensure clinical improvement. Participants in the control arm will receive appendicectomy. Randomisation will be minimised by age, sex, duration of symptoms and centre. Children and families who are approached for the RCT will be invited to participate in the embedded qualitative substudy, which includes recording of recruitment consultants and subsequent interviews with participants and non-participants and their families and recruiters. Analyses of these will inform interventions to optimise recruitment. The main study outcomes include recruitment rate (primary outcome), identification of strategies to optimise recruitment, performance of trial treatment pathways, clinical outcomes and safety of non-operative treatment. We have involved children, young people and parents in study design and delivery.DiscussionIn this study we will explore the feasibility of performing a full efficacy RCT comparing non-operative treatment with appendicectomy in children with acute uncomplicated appendicitis. Factors determining success of the present study include recruitment rate, safety of non-operative treatment and adequate interest in the future RCT. Ultimately this feasibility study will form the foundation of the main RCT and reinforce its design.Trial registrationISRCTN15830435. Registered on 8 February 2017.

Development of a core outcome set to determine the overall treatment success of acute uncomplicated appendicitis in children: a study protocol

IntroductionIn recent years, there has been growing interest in alternatives to appendicectomy. In particular, non-operative treatment of appendicitis, with antibiotics alone, has been proposed as a potential treatment. A small...

The influence of underweight and obesity on the diagnosis and treatment of appendicitis in children.

PurposeThe impact of lower body mass index (BMI) on appendicitis has never been addressed. We investigated whether different BMIs affect the diagnosis and treatment of appendicitis in children.MethodsThe correlation between BMI and diagnosis accuracy and treatment quality was evaluated by retrospective analysis of 457 children diagnosed with appendicitis. Based on BMI percentiles, patients were classified as either underweight (n = 36), normal weight (n = 346), overweight (n = 59), or obese (n = 16). Diagnosis accuracy was measured by negative appendectomy rate, perforation rate, and number of consultations. Treatment quality was measured by complication rate and length of hospital stay.ResultsUnderweight patients had the highest negative appendectomy (OR 3.00, P = 0.008) and complication (OR 2.75, P = 0.041) rate. BMI did not influence perforation rate or number of consultations. Both underweight and obese patients stayed in the hospital longer than normal weight patients (regression coefficient 2.34, P = 0.001, and regression coefficient 9.40, P < 0.001, respectively).Furthermore, in obese patients, the hospital stay after open appendectomy was prolonged compared to laparoscopic appendectomy (P < 0.001). No such differences were observed in patients with lower BMI.ConclusionsUnderweight children are misdiagnosed more often, stay in hospital longer, and experience more postoperative complications than children of normal weight. Obesity is associated with longer hospital stays. Laparoscopic appendectomy might shorten the length of hospital stays in these patients. We conclude that in addition to obesity, underweight should also be considered a risk factor for children with appendicitis.

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

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

Impact of experience on quality outcomes in single-incision laparoscopy for simple and complex appendicitis in children

BackgroundSingle-incision laparoscopic appendectomy (SILA) is an effective treatment for appendicitis in children. We report our experience with SILA, focusing on how surgeon experience may impact quality outcomes. MethodsA retrospective review of patients who underwent SILA from August 2009 to November 2013 was performed. Patients were grouped by early experience, late experience without surgical trainees, and late experience with trainees and further stratified into simple and complex appendicitis. ResultsSILA was performed on 703 patients with a mean age of 11.8±3.9years. Four hundred eleven (58.5%) patients were diagnosed with simple and 292 (41.5%) with complex appendicitis. There was a significant decrease in operative time between early and late groups for both simple and complex appendicitis. Following the introduction of surgical trainees, there was a significant increase in operative time compared to the late group for simple appendicitis. There were no significant differences in complication rates between any of the groups. ConclusionThe adoption of SILA requires a significant learning curve even for the experienced laparoscopist with the potential for decreased operative times with experience. While there may be an increase in operative time with the introduction of trainees, this does not impact quality outcomes.

Financial Impact of Surgical Technique in the Treatment of Acute Appendicitis in Children

Appendicitis is the most common emergent problem encountered by pediatric surgeons. Driven by improved cosmetic outcomes, many surgeons are offering pediatric patients single-incision laparoscopic appendectomy. We sought to investigate the financial impact of different surgical approaches to appendectomy. A retrospective study of patients with acute appendicitis undergoing appendectomy from February 2010 to September 2011 was conducted. Based on surgeon preference, patients underwent open appendectomy (OA), laparoscopic appendectomy (LA), or single-incision laparoscopic appendectomy (SILA). Demographic information, surgical outcomes, surgical supply costs, and total direct costs were recorded. A total of 465 patients underwent appendectomy during the study. The mean age of all patients was 11.2 years (range, 1 to 18 years). There were no conversions in the LA or SILA groups. There was a significant difference among surgical technique in regard to surgical supply costs (OA $159 vs. LA $650 vs. SILA $814, P < 0.01) and total direct costs (OA $2129 vs. LA $2624 vs. SILA $2991, P < 0.01). In our institution, both multiport laparoscopic and SILA carry higher costs when compared with OA, largely as a result of the cost of disposable instrumentation. Cost efficiency should be considered by surgeons when undertaking a minimally invasive approach to appendectomy.

Single Daily Dosing of Ceftriaxone and Metronidazole is as Safe and Effective as Ampicillin, Gentamicin and Metronidazole for Non-operative Management of Complicated Appendicitis in Children

Introduction: Perforated appendicitis very common abdominal emergency in children and nonoperative management with Ampicillin Gentamicin and Metronidazole (AGM) has shown good results. Recent data show that single daily dosing of Ceftriaxone and Metronidazole (CM) is as safe and effective as ampicillin gentamicin and clindamycin for treatment of perforated appendicitis after surgery in children. Treatment of complicated appendicitis in children with once daily CM can decrease the risk of in drug administration’s mistake, require the patient to be connected to the IV line for short time only once a day, may cause less IV line infection and may cost less. The aim of this study was to compare the effectiveness, and safety of CM with the traditional triple antibiotic for conservative treatment of complicated appendicitis children. Methods: A prospective, open, randomized study conducted from July 1st 2008 to June 30th 2009. Included were children younger than 14 years with complicated appendicitis who were randomly assigned to therapy with either CM as a single daily dose or AGM. The outcome variables compared were maximum daily temperature, duration of fever, time return to oral diet, length of antibiotic therapy, results of repeat WBC counts, need for abdominal abscess drainage, length of hospitalization and complication. Results: Overall 22 and 21 children were assigned to CM and AGM regimens respectively. There were no any significant differences in all clinical outcomes parameters between the two groups. Conclusions: Single daily dosing of CM is as safe and effective as the triple antibiotic regimen and has significant advantages for the conservative therapy of complicated appendicitis in children.

An evidence-based clinical protocol for diagnosis of acute appendicitis decreased the use of computed tomography in children

Purpose The increased use of computed tomography (CT) to diagnose appendicitis in children has led to a concern for the possibility of increased CT-related cancer morbidity. We designed a clinical protocol for the diagnosis and treatment of appendicitis in children in an attempt to decrease the use of CT scans at our institution. Methods Patients who had surgical consultation for suspected appendicitis were placed on the clinical protocol. Data concerning diagnosis and treatment were collected prospectively. Retrospective data from patients admitted to our institution with acute appendicitis before the clinical protocol were collected as historical controls. Results One hundred twelve patients were diagnosed and treated by our protocol between June and November 2009. Of these, 100 patients underwent an appendectomy for acute appendicitis. They were compared with 146 patients from 2007. In-house CT use decreased from 71.2% to 51.7% ( P = .01). Preoperative ultrasound use increased from 2.7% to 21% ( P < .001). The negative appendectomy rate increased (6.8% vs 11%, P = .25). Conclusions Our findings suggest that the implementation of an evidence-based clinical protocol for the diagnosis and treatment of acute appendicitis in children may safely decrease the use of CT scans and increase the use of ultrasound.

Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee Systematic Review

Objective The aim of the study was to review evidence-based data regarding the use of antibiotics for the treatment of appendicitis in children. Data Source Data were obtained from PubMed, MEDLINE, and citation review. Study Selection We conducted a literature search using “appendicitis” combined with “antibiotics” with children as the target patient population. Studies were selected based on relevance for the following questions: (1) What perioperative antibiotics should be used for pediatric patients with nonperforated appendicitis? (2) For patients with perforated appendicitis treated with appendectomy: a. What perioperative intravenous antibiotics should be used? b. How long should perioperative intravenous antibiotics be used? c. Should oral antibiotics be used? (3) For patients with perforated appendicitis treated with initial nonoperative management, what antibiotics should be used in the initial management? Results Children with nonperforated appendicitis should receive preoperative, broad-spectrum antibiotics. In children with perforated appendicitis who had undergone appendectomy, intravenous antibiotic duration should be based on clinical criteria. Furthermore, broad-spectrum, single, or double agent therapy is as equally efficacious as but is more cost-effective than triple agent therapy. If intravenous antibiotics are administered for less than 5 days, oral antibiotics should be administered for a total antibiotic course of 7 days. For children with perforated appendicitis who did not initially undergo an appendectomy, the duration of broad-spectrum, intravenous antibiotics should be based on clinical symptoms. Conclusions Current evidence supports the use of guidelines as described above for antibiotic therapy in children with acute and perforated appendicitis.

Acute Appendicitis in Latino Children: Do Health Disparities Exist

Introduction: Significant racial and socioeconomic disparities have been found in the diagnosis and treatment of appendicitis in children. There has been little focus on the outcomes of Latino children with appendicitis. This study evaluates whether ethnicity or insurance status are associated with differences in presentation and outcomes children with acute appendicitis. Methods: A retrospective analysis was performed for all children between the ages of 2 and 18 years of age with appendicitis between July 1, 2005 and December 31, 2008 at the only teaching hospital in the region.

Laparoscopic versus open appendectomy in the treatment of complicated appendicitis in children: an analysis of 268 cases

Laparoscopic versus open appendectomy in the treatment of complicated appendicitis in children: an analysis of 268 cases

Does Computed Tomography Delay Diagnosis and Treatment of Acute Appendicitis in Children?

Does Computed Tomography Delay Diagnosis and Treatment of Acute Appendicitis in Children?