Uncomplicated Appendicitis In Children Research Articles

Non-Operative Management of Uncomplicated Appendicitis in Children: Can Patients Be Discharged From the Emergency Department?

IntroductionNon-operative management of uncomplicated appendicitis in children is a safe alternative to laparoscopic appendectomy. The purpose of this study is to determine the feasibility of nonoperative outpatient management of uncomplicated appendicitis in pediatric patients. MethodsA standardized pathway for non-operative outpatient management of uncomplicated appendicitis in children (NOMA-C) was implemented in a university pediatric surgery practice starting October 2021. Those who met criteria would be considered for discharge from the emergency department (ED) with oral antibiotics and close followup over the following year. A quality improvement project started concurrently to monitor patients for recurrent symptoms of appendicitis. ResultsA total of 121 patients were diagnosed with acute appendicitis during the study period (October 2021 to April 2023). Forty-five children (38%) met criteria for the NOMA-C protocol, and 11 patients/families chose appendectomy. Of the 34 patients who pursued nonoperative management, 14 patients were admitted to the hospital and 20 patients were discharged from the ED. Total time in the ED/hospital was significantly shorter for patients discharged from the ED (7 hours versus 23 hours; p<0.001). At one year follow up only 4 (12%) had undergone appendectomy. There were no adverse events for patients who underwent nonoperative management. ConclusionA protocol offering non-operative management of appendicitis with an option for outpatient management was feasible and safe. Outpatient management was associated with shorter ED/hospital stays than those admitted. Future studies should evaluate whether this protocol can be adopted by EDs without pediatric surgery services to avoid the need for transfer.

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

Introduction/Objective. The objective was 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 during a 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 6 mm had the highest sensitivity (93.2%), while wall thickness &gt; 3 mm was the most specific (95.2%). Conclusion. Using periappendiceal 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.

Acute appendicitis in children: is preoperative hyponatremia a predictive factor of perforation/gangrene? A prospective study

PurposeDistinguishing between perforated/gangrenous from uncomplicated appendicitis in children helps management. We evaluated hyponatremia as a new diagnostic marker for perforated/gangrenous appendicitis in children.MethodsA prospective study including all children with acute appendicitis who underwent appendectomy at our institution from May 2021 to May 2023. Medical history and clinical criteria were analyzed. All blood samples were taken upon admission including serum inflammatory markers and electrolytes. Patients were divided into two groups (Group I: uncomplicated and Group II: perforated/gangrenous), and data between both groups were compared.ResultsThe study included 153 patients [Group I: 111 (73%), Group II: 42 (27%)]. Mean serum sodium concentration in children with perforated/gangrenous appendicitis was significantly lower compared to children with uncomplicated appendicitis (131.8 mmol/L vs. 138.7 mmol/L; p < 0.001). The ROC curve of preoperative sodium level to differentiate between perforated/gangrenous and uncomplicated appendicitis revealed an AUC of 0.981. The cut-off-value of sodium level < 135 mmol/L identified perforated/gangrenous appendicitis with a sensitivity of 94% and a specificity of 91% (p < 0.001). Predictive factors of perforated/gangrenous appendicitis were: age less than 5 years (12% vs. 3%; p = 0.02), experiencing symptoms for more than 24 h (100% vs. 58%; p < 0.001), body temperature more than 38.5 °C (52% vs. 13%; p < 0.001), a serum sodium level less than 135 mmol/L (90% vs. 6%; p < 0.001), and a CRP serum level more than 50 mg/L (71% vs. 17%; p < 0.001).ConclusionsHyponatremia, upon admission, is a novel, objective biochemical marker that can identify perforated/gangrenous appendicitis in children. We advocate that the assessment of serum sodium level should be added to the diagnostic algorithm in children with suspected acute appendicitis. Surgical intervention in patients with hyponatremia should not be delayed, and non-operative management should be avoided.

Outcomes 1 year after non-operative management of uncomplicated appendicitis in children: Children with AppendicitiS during the CoronAvirus panDEmic (CASCADE) study.

A major shift in treatment of appendicitis occurred early in the SARS-CoV-2 pandemic with non-operative management used commonly outside research protocols and in units with limited previous experience. This study aims to compare real-world outcomes of surgery versus non-operative management of uncomplicated appendicitis in children with 1-year follow-up. A prospective multicentre observational study of children treated for uncomplicated appendicitis at 74 hospitals in the UK and Ireland from 1 April to 31 July 2020 was performed. Propensity-score matched analysis was conducted using age, sex, C-reactive protein at diagnosis and duration of symptoms as covariates. Primary outcomes were success of non-operative management defined as achieving 1-year follow-up without undergoing appendicectomy due to recurrent appendicitis or ongoing symptoms, and occurrence of any predefined complication (intra-abdominal collection, wound infection, bowel obstruction or reintervention). Of 1464 children with presumed uncomplicated appendicitis, 1027 (70.2 per cent) underwent surgery and 437 (29.9 per cent) underwent non-operative management. Ninety-four children (21.5 per cent) treated by initial non-operative management required appendicectomy during the index hospital admission while recurrent appendicitis after discharge occurred in 25 (10.4 per cent) children within 1 year. The overall success rate of non-operative management at 1 year was 63.1 per cent (95 per cent c.i. 58.0 to 68.3 per cent). For propensity-score matched analyses, 688 children undergoing surgery and 307 undergoing non-operative management were included. Any predefined complication occurred in 50 (7.3 per cent) children undergoing surgery and in four (1.3 per cent) children undergoing non-operative management (OR 5.9 (95 per cent c.i. 2.1 to 16.6)) in the propensity-score matched cohort. There was no mortality or stoma formation. Non-operative management is a safe and valid alternative to appendicectomy in children with uncomplicated appendicitis.

Clinical Outcomes of Non-Operative Treatment of Suspected Uncomplicated Appendicitis in Children

Aim&#x0D; Non-operative treatment approach is another method used in the treatment of uncomplicated appendicitis, in which the infection in the appendix is suppressed and treated with antibiotics. Our study aims to investigate the clinical outcomes and the risk factors for recurrence in our pediatric patients with suspected uncomplicated appendicitis, who underwent non-operative treatment.&#x0D; Methods&#x0D; The medical data of the patients who underwent non-operative treatment with the diagnosis of suspected uncomplicated appendicitis between January 2016 and January 2021 in a tertiary pediatric surgery center were analyzed. Demographic data, treatment process, and clinical results of the patients were recorded. Statistical evaluation was made by comparing the two groups with and without recurrence after non-operative treatment.&#x0D; Results&#x0D; The median age of 41 patients whose data were evaluated was 13 (6-17) years. Eight patients (19.5%) had appendicolith. The median duration of IV antibiotic treatment was 4 (3-7) days, and the patients' abdominal tenderness disappeared in a median of 2 (1-4) days. Recurrence developed in 8 (19.5%) patients after a median of 7 (1-14) months after non-operative treatment. It was found that the time to the disappearance of abdominal tenderness was statistically longer in the group that developed recurrence than that in the group that did not (p=0.01).&#x0D; Conclusion&#x0D; Our study revealed that appendicolith was not a risk factor for the development of recurrence. The time to the disappearance of abdominal tenderness may be useful for detecting patients at a higher risk of recurrence.

Non-Operative Management of Acute Uncomplicated Appendicitis in Children

Objective: To compare the efficacy of non-surgical conservative management with surgical management in cases of uncomplicated acute appendicitis in children.&#x0D; Study design: Prospective comparative study.&#x0D; Settings: Pediatric surgery Department, Ghulam Muhammad Mahar Medical College Sukkur.&#x0D; Study duration: 1st February 2020 to 31st May 2021.&#x0D; Materials and Methods: Ninety patients of either gender with age range from 5-12 years, diagnosed as uncomplicated acute appendicitis, were divided in two groups. Group C patients were managed conservatively with antibiotics (ceftriaxone 100 mg/kg/day, amikacin 10mg/kg/day and metronidazole 22.5 mg/kg/day) and maintenance fluids were started. Patients were observed for improvement or any signs of deterioration. Those who deteriorated within 24 hours were managed with surgical management immediately. Follow-ups were carried out after discharge on the 7th day, 1 month, and six months. Patients reporting a recurrence of symptoms were managed with appendicectomy. Group S patients were managed with appendicectomy with the open technique. Patients were observed for post-operative complications.&#x0D; Results: Demographic data of both groups was comparable. In group C, 34 (75.56%) patients were successfully treated with conservative management, whereas in group S, 39 (86.67%) were successfully treated with surgical management. The difference was insignificant with a p-value of 0.114. In group C, 5 (11.11%) patients did not respond to conservative management and they were managed with appendicectomy and recurrence of symptoms was seen in 6 (13.33%) patients in group C, they were also managed with appendicectomy. In group S, 6 (13.33%) patients suffered post-operative complications. Mean length of stay in hospital was 4.31±1.20 and 4.09±1.12 days in group C and S respectively. This difference was statistically insignificant with a p-value of 0.368.&#x0D; Conclusion: It is concluded in our study that uncomplicated acute appendicitis in children can be successfully managed with non-surgical conservative management.

New Criteria Could Improve the Success Rate of Non-operative Management of Acute Appendicitis in Children.

Background: Most studies addressing non-operative management for acute appendicitis have focused on adults, and there are limited data available for children. We aimed to evaluate the results of successful non-operative management in children with acute uncomplicated appendicitis with our “additional criteria” and find which factors could be affecting the success rate and which cases could be candidates for non-operative management.Materials and methods: A total of 54 patients who were diagnosed with acute uncomplicated appendicitis and received non-operative management were re-evaluated retrospectively. Defining uncomplicated appendicitis was based on the duration of symptoms (<24 hours), clinical history, and radiologic findings. The radiologic evaluation was based on ultrasonography and computed tomography. The patients received an intravenous antibiotic combination (sulbactam/ampicillin, gentamicin, clindamycin) for five days at the hospital; the treatment was completed after 10 days with an oral antibiotic combination (amoxicillin/clavulanate, metronidazole). The cases have a follow-up period of up to two years.Results: The mean patient age and follow-up time were 13.0 ± 4 years and 41.6 ± 13 months, respectively. The mean leukocyte count, C-reactive protein (CRP), and appendix diameter values were 15.48 ± 6.4 × 109/L, 11.79 ± 24.5 mg/dL, and 7.76 ± 1.4 mm on admission, and 6.86 ± 12.4 × 109/L, 4.17 ± 10.3 mg/dL, and 5.82 ± 1.6 mm on the second day, respectively. This decrease in WBC/CRP values and appendix diameter was statistically significant (p < 0.001). None of the patients had an early failure, complication, or adverse event. Recurrent appendicitis occurred in only five cases (9%) that were treated by laparoscopic appendectomy during the follow-up.Conclusion: Non-operative management for acute uncomplicated appendicitis in children regarding long-term outcomes with our criteria was satisfactory and initial success rates were excellent.

Demographic and Clinical Characteristics Associated With the Failure of Nonoperative Management of Uncomplicated Appendicitis in Children

The factors associated with the failure of nonoperative management of appendicitis and the differences in patient-reported outcomes between successful and unsuccessful nonoperative management remain unknown. To investigate factors associated with the failure of nonoperative management of appendicitis and compare patient-reported outcomes between patients whose treatment succeeded and those whose treatment failed. This study was a planned subgroup secondary analysis conducted in 10 children's hospitals that included 370 children aged 7 to 17 years with uncomplicated appendicitis enrolled in a prospective, nonrandomized clinical trial between May 1, 2015, and October 31, 2018, with 1-year follow-up comparing nonoperative management with antibiotics vs surgery for uncomplicated appendicitis. Statistical analysis was performed from November 1, 2019, to February 12, 2022. Nonoperative management with antibiotics vs surgery. Failure of nonoperative management and patient-reported outcomes. The relative risk (RR) of failure based on sociodemographic and clinical characteristics was calculated. Patient-reported outcomes were compared based on the success or failure of nonoperative management. Of 370 patients (34.6% of 1068 total patients; 229 boys [61.9%]; median age, 12.3 years [IQR, 10.0-14.6 years]) enrolled in the nonoperative group, treatment failure occurred for 125 patients (33.8%) at 1 year, with 53 patients (14.3%) undergoing appendectomy during initial hospitalization and 72 patients (19.5%) experiencing delayed treatment failure after hospital discharge. Higher patient-reported pain at presentation was associated with increased risk of in-hospital treatment failure (RR, 2.1 [95% CI, 1.0-4.4]) but not delayed treatment failure (RR, 1.3 [95% CI, 0.7-2.3]) or overall treatment failure at 1 year (RR, 1.5 [95% CI, 1.0-2.2]). Pain duration greater than 24 hours was associated with decreased risk of delayed treatment failure (RR, 0.3 [95% CI, 0.1-1.0]) but not in-hospital treatment failure (RR, 1.2 [95% CI, 0.5-2.7]) or treatment failure at 1 year (RR, 0.7 [95% CI, 0.4-1.2]). There was no increased risk of treatment failure associated with age, white blood cell count, sex, race, ethnicity, primary language, insurance status, transfer status, symptoms at presentation, or imaging results. Health care satisfaction at 30 days and patient-reported, health-related quality of life at 30 days and 1 year were not different. Satisfaction with the decision was higher with successful nonoperative management at 30 days (28.0 vs 27.0; difference, 1.0 [95% CI, 0.01-2.0]) and 1 year (28.1 vs 27.0; difference, 1.1 [95% CI, 0.2-2.0]). This analysis suggests that a higher pain level at presentation was associated with a higher risk of initial failure of nonoperative management and that a longer duration of pain was associated with lower risk of delayed treatment failure. Although satisfaction was high in both groups, satisfaction with the treatment decision was higher among patients with successful nonoperative management at 1 year. ClinicalTrials.gov Identifier: NCT02271932.

Nonoperative Management of Uncomplicated Appendicitis.

Several studies have revealed the success of nonoperative management (NOM) of uncomplicated appendicitis in children. Large studies of current NOM utilization and its outcomes in children are lacking. We queried the Pediatric Health Information System database to identify children <19 years of age with a diagnosis code for appendicitis. We used linear trend analysis to assess the subsequent utilization and outcomes of NOM in children with nonperforated appendicitis over time. We calculated the proportion of children experiencing treatment failure, defined as either a subsequent appendectomy or hospitalization with a diagnosis code of perforated appendicitis. We identified 117 705 children with appendicitis over the 9-year study period. Of the 73 544 children with nonperforated appendicitis, 10 394 (14.1%) underwent NOM. The odds of NOM significantly increased (odds ratio 1.10 per study quarter, 95% confidence interval [CI] 1.05-1.15). The 1-year and 5-year failure rates were 18.6% and 23.3%, respectively. Children who experienced failure of NOM had higher rates of perforation at the time of failure than did the general cohort at the time of initial presentation (45.7% vs 37.5%, P < .001). Patients undergoing NOM had higher rates of subsequent related emergency department visits (8.0% vs 5.1%, P < .001) and hospitalizations (4.2% vs 1.4%, P < .001) over a 12-month follow-up period. NOM of nonperforated appendicitis in children is increasing. Although the majority of children who undergo NOM remain recurrence-free years later, they carry a substantial risk of perforation at the time of recurrence and may experience a higher rate of postoperative complications than children undergoing an immediate appendectomy.

Same-day discharge after appendectomy for uncomplicated appendicitis in children: Potential barriers to increased utilization

BackgroundUtilization of same-day discharge (SDD) after appendectomy for uncomplicated appendicitis (UA) was closely examined to explore potential barriers to greater use of SDD. MethodsChildren (≤18 years) who underwent appendectomy for UA between 2015 and 2019 at a tertiary care children's hospital were reviewed. Associations with SDD were evaluated using multivariable regression models. ResultsAmong 973 children, SDD was less frequently utilized after appendectomy performed between 12pm and 5pm (aOR 0.14, p < 0.001) and after 5pm (aOR 0.01, p < 0.001) compared to before 12pm. SDD utilization was also less frequent in those from lower resource neighborhoods (adjusted odds ratio [aOR] 0.90 per decile increase in Area Deprivation Index, p = 0.04), females (aOR 0.53, p = 0.005), and patients residing 30–60 min away (aOR 0.56, p = 0.04) compared to <30 min away. ConclusionsSDD utilization was primarily impacted by operative timing and socioeconomic and travel factors, focuses for quality improvement efforts to further increase utilization of SDD.

Keep it Simple, Laboratory Parameters to Predict Complicated Acute Appendicitis in Children Younger Than Five Years.

The clinical presentation of acute appendicitis in the youngest age lacks specific signs and symptoms, and it is difficult to obtain an accurate clinical diagnosis. Once the diagnosis is made, it is necessary to determine if the appendicitis is simple and able to be managed non-surgically, or complicated, therefore requiring surgery. Together with the clinical picture and imaging, routine laboratory values play a vital role in this decision. The aim of this study is to evaluate routine blood in their ability to differentiate between complicated and uncomplicated acute appendicitis. A retrospective analysis was conducted from a single pediatric surgery department of all children 5years of age or younger who underwent surgery for acute appendicitis between the years 2010-2020. 728 children were diagnosed with acute appendicitis, and 42 children were under the age of 5years. There was a significant difference in the C-reactive protein, white blood cell count, neutrophil/lymphocyte ratio, and platelet/lymphocyte ratio in the complicated group versus the uncomplicated group. The value of these together for prediction complicated appendicitis were 84.8% sensitivity, 80.9% specificity, 82.8% positive predictive value, and 72.8% negative predictive value. These values were all higher than both the Alvarado score and the PAS (P < .05). C-reactive protein, neutrophil/lymphocyte ratio, and platelet/lymphocyte ratio are simple laboratory parameters that can help identify complicated versus uncomplicated appendicitis in children 5years old or younger. These universal parameters may help guide the treatment and decision to operate on a difficult to diagnose population.

Initial experience with single incision laparoscopic appendectomy.

Within the development of laparoscopy, the single incision laparoscopy method has been recently introduced in paediatric surgery. The aim of this study was to evaluate the initial experience with single incision laparoscopic appendectomy at the Department of Paediatric Surgery, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague. A consecutive cohort of paediatric patients (18 years) undergoing laparoscopic single incision surgery for uncomplicated appendicitis between 4/30/2019 and 4/30/2021 was retrospectively evaluated. The following parameters were monitored: patients demographic characteristics, perioperative course, surgery duration, number and method of surgery conversions, length of postoperative hospitalization, postoperative complications classified according to Clavien-Dindo classification, occurrence of incisional hernias, and length of follow-up. In all, 160 patients (72 (45%) females) with uncomplicated appendicitis were included in the study. The median age at the time of surgery was 12 (IQR: 9.914.9) years. The median duration of surgery was 50 (IQR: 3860) minutes. Only one conversion to multiport laparoscopy and no conversion to open surgery were reported. The median postoperative hospital stay was 2 (IQR: 23) days. We observed 5 intra-abdominal and 9 wound complications. Single incision laparoscopic appendectomy is a safe, effective and rapidly adoptable method for the treatment of uncomplicated appendicitis in children.

A Systematic Review Comparing Nonoperative Management to Appendectomy for Uncomplicated Appendicitis in Children.

More than a century after its introduction, appendectomy has remained the gold standard treatment for acute appendicitis. In adults with acute uncomplicated appendicitis, nonoperative management (NOM) has been shown to be a viable treatment option. To date, there has been relatively limited data on the nonoperative management of acute appendicitis in the pediatric population. The primary objective of this study was to systematically review the available literature in the pediatric population and compare the efficacy and recurrence between initial nonoperative treatment strategy and appendectomy in children with uncomplicated appendicitis. In July 2021, we conducted systematic searches of the PubMed and Google Scholar databases. We only included full-text comparative original studies published within the last decade, and we excluded articles that solely examined NOM without comparing it to appendectomy. Two writers worked independently on the data collection and analysis. It was found that NOM had a high initial success rate and a low rate of recurrent appendicitis. After months of follow-up, the vast majority of patients with uncomplicated acute appendicitis who received initial nonoperative treatment did not require surgical intervention. Furthermore, the rate of complication was comparable in both treatment groups, and NOM did not appear to be associated with an increased risk of complications. The most significant drawback stemmed from the fact that the included articles in this study had a wide range of study designs and inclusion criteria. According to current evidence, NOM is feasible and cost-effective. Antibiotic therapy can be given safely in a small subset of individuals with uncomplicated appendicitis. To optimize outcomes, physicians should evaluate the clinical presentation and the patient's desire when selecting those to be managed nonoperatively. Again, more research, preferably large randomized trials, is required to compare the long-term clinical efficacy of NOM with appendicectomy. Finally, additional research is required to establish the characteristics of patients who are the best candidates for nonoperative treatment.

Conservative treatment for uncomplicated appendicitis in children: the CONTRACT feasibility study, including feasibility RCT.

Although non-operative treatment is known to be effective for the treatment of uncomplicated acute appendicitis in children, randomised trial data comparing important outcomes of non-operative treatment with those of appendicectomy are lacking. The objectives were to ascertain the feasibility of conducting a multicentre randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of a non-operative treatment pathway with appendicectomy for the treatment of uncomplicated acute appendicitis in children. This was a mixed-methods study, which included a feasibility randomised controlled trial, embedded and parallel qualitative and survey studies, a parallel health economic feasibility study and the development of a core outcome set. This study was set in three specialist NHS paediatric surgical units in England. Children (aged 4-15 years) clinically diagnosed with uncomplicated acute appendicitis participated in the feasibility randomised controlled trial. Children, their families, recruiting clinicians and other health-care professionals involved in caring for children with appendicitis took part in the qualitative study. UK specialist paediatric surgeons took part in the survey. Specialist paediatric surgeons, adult general surgeons who treat children, and children and young people who previously had appendicitis, along with their families, took part in the development of the core outcome set. Participants in the feasibility randomised controlled trial were randomised to a non-operative treatment pathway (broad-spectrum antibiotics and active observation) or appendicectomy. The primary outcome measure was the proportion of eligible patients recruited to the feasibility trial. Data were sourced from NHS case notes, questionnaire responses, transcribed audio-recordings of recruitment discussions and qualitative interviews. Overall, 50% (95% confidence interval 40% to 59%) of 115 eligible patients approached about the trial agreed to participate and were randomised. There was high acceptance of randomisation and good adherence to trial procedures and follow-up (follow-up rates of 89%, 85% and 85% at 6 weeks, 3 months and 6 months, respectively). More participants had perforated appendicitis than had been anticipated. Qualitative work enabled us to communicate about the trial effectively with patients and families, to design and deliver bespoke training to optimise recruitment and to understand how to optimise the design and delivery of a future trial. The health economic study indicated that the main cost drivers are the ward stay cost and the cost of the operation; it has also informed quality-of-life assessment methods for future work. A core outcome set for the treatment of uncomplicated acute appendicitis in children and young people was developed, containing 14 outcomes. There is adequate surgeon interest to justify proceeding to an effectiveness trial, with 51% of those surveyed expressing a willingness to recruit with an unchanged trial protocol. Because the feasibility randomised controlled trial was performed in only three centres, successful recruitment across a larger number of sites cannot be guaranteed. However, the qualitative work has informed a bespoke training package to facilitate this. Although survey results suggest adequate clinician interest to make a larger trial possible, actual participation may differ, and equipoise may have changed over time. A future effectiveness trial is feasible, following limited additional preparation, to establish appropriate outcome measures and case identification. It is recommended to include a limited package of qualitative work to optimise recruitment, in particular at new centres. Prior to proceeding to an effectiveness trial, there is a need to develop a robust method for distinguishing children with uncomplicated acute appendicitis from those with more advanced appendicitis, and to reach agreement on a primary outcome measure and effect size that is acceptable to all stakeholder groups involved. Current Controlled Trials ISRCTN15830435. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 10. See the NIHR Journals Library website for further project information.

Non-operative treatment versus appendectomy for acute uncomplicated appendicitis: A randomized controlled trial.

Objectives:To compare the outcome of non-operative treatment (NOT) with antibiotics versus surgical management of uncomplicated appendicitis in children.Methods:This randomized clinical trial (NCT 04030741) was carried out in Pediatric Surgery Department, Mayo Hospital from September 2018 to September 2019. Total sample size was 180, and after informed consent patients were randomly allocated in two groups. All children between 5 and 15 years of age and having pediatric appendicitis score (PAS) >7 were included. Patients with previous abdominal surgery, peritonitis, appendicular mass, or intra-abdominal abscess were excluded. Children in NOT group (Group A) were given intravenous Meropenem and Metronidazole for 48 hours and after starting oral, antibiotics were continued orally for 7 days. In Group B, children underwent appendectomy. Failure of NOT was labeled if there was abscess formation or peri-appendiceal fluid collection on ultrasound, development of peritonitis or recurrence of appendicitis.Results:In Group A, mean age was 9.56±1.8 years and in Group B 10.11±1.8 years. There were 123 male and 57 female patients. Group B had 100% successful outcome. NOT (Group A) had successful outcome in 75 patients (83.3%) and failure was noted in 15 (16.7%). Five needed operation within 48 hours, all had appendicolith, and 10 patients presented within 6 months. Raised total leukocyte count (p value < 0.0001) and C reactive protein (p value < 0.04) levels were noted with failure of NOT.Conclusions:In this study, success of NOT was 84% so a trial of NOT in cases of uncomplicated appendicitis should be considered in children.

The modified endoscopic retrograde appendicitis therapy versus antibiotic therapy alone for acute uncomplicated appendicitis in children.

Endoscopic retrograde appendicitis therapy (ERAT) is an emerging endoscopic treatment modality for acute uncomplicated appendicitis (AUA) supported by several case series. However, to date, systematic studies have not been conducted in children and the prospective comparative data are lacking. Moreover, due to a concern for future malignancy risk in children from ionizing radiation, we used contrast-enhanced ultrasound (CEUS) instead of endoscopic retrograde appendiceal radiography (ERAR). Therefore, we conducted a prospective, randomized control clinical trial to compare the modified ERAT (mERAT) to antibiotic therapy in children with AUA. The aim of this study was to evaluate the safety and feasibility and of mERAT in the treatment of hospitalized children with AUA. Children with AUA, confirmed by ultrasonography and or abdominal computed tomography, were consecutively enrolled from October 2018 to February, 2020. They were randomly assigned to receive mERAT or routine antibiotic treatment. Patients were followed until May, 2020. Th primary outcome variable was the duration of relief of the abdominal pain after treatment. We collected patient's demographics, ultrasonic imaging findings, colonoscopy findings, and treatment outcomes of the mERAT and adverse even associated with mERAT. A total of 83 children were enrolled. 36 were randomized to mERAT and 47 to antibiotics treatment. All children in the mERAT group had endoscopic confirmed acute uncomplicated appendicitis, and there were no significant complications. However, 9 of patients in antibiotic group were poor responsive to treatment and switched to mERAT. The overall success rate of treatment with mERAT (100%) was significantly higher than that of antibiotics (80.9%) (P = 0.004). The median time to discharge was significantly shorter in mERAT group than in antibiotics treatment group [6.0 ± 1.76days] (P = 0.004). mERAT provide a new alternative therapeutic option for childhood with AUA, especially for families who are reluctant to undergo an appendectomy.

Success of Antibiotic Therapy vs Laparoscopic Appendectomy for Uncomplicated Appendicitis in Children

Success of Antibiotic Therapy vs Laparoscopic Appendectomy for Uncomplicated Appendicitis in Children

Management of early appendicular lump in children - laparoscopic technique versus open surgery: a comparative study in low-middle income country perspective

BackgroundIn the pediatric population, appendectomy is one of the most common emergency operations. Laparoscopic appendectomy (LA) is an accepted way of dealing with suspected uncomplicated appendicitis in children. The role...

Ceftriaxone Combined With Metronidazole is Superior to Cefoxitin Alone in the Management of Uncomplicated Appendicitis in Children: Results from a Multicenter Collaborative Comparative Effectiveness Study.

To compare rates of surgical site infection between the 2 most commonly utilized narrow-spectrum antibiotic regimens in children with uncomplicated appendicitis (ceftriaxone with metronidazole and cefoxitin alone). Narrow-spectrum antibiotics have been found to be equivalent to extended-spectrum (antipseudomonal) agents in preventing surgical site infection (SSI) in children with uncomplicated appendicitis. The comparative effectiveness of different narrow-spectrum agents has not been reported. This was a multicenter retrospective cohort study using clinical data from the Pediatric National Surgical Quality Improvement Program Appendectomy Collaborative Pilot database merged with antibiotic utilization data from the Pediatric Health Information System database from January 2013 to June 2015. Multivariable logistic regression was used to compare outcomes between antibiotic treatment groups after adjusting for patient characteristics, surrogate measures of disease severity, and clustering of outcomes within hospitals. Eight hundred forty-six patients from 14 hospitals were included in the final study cohort with an overall SSI rate of 1.3%. A total of 56.0% of patients received ceftriaxone with metronidazole (hospital range: 0%-100%) and 44.0% received cefoxitin (range: 0%-100%). In the multivariable model, ceftriaxone with metronidazole was associated with a 90% reduction in the odds of a SSI compared to cefoxitin [0.2% vs 2.7%; odds ratio: 0.10 (95% confidence interval 0.02-0.60); P = 0.01]. Ceftriaxone combined with metronidazole is superior to cefoxitin alone in preventing SSIs in children with uncomplicated appendicitis.

Single-port laparoscopic appendectomy using a needle-type grasping forceps for acute uncomplicated appendicitis in children: Case series

IntroductionSingle-port laparoscopy has been used in any areas of surgery, including appendectomy, to reduce the operative stress and enhance postoperative recovery procedure. This paper introduces our attempt to perform single-port laparoscopic appendectomy using conventional laparoscoopic instruments and a needle-type grasping forceps (SLAN), which has dominant advantage in cosmetic appearance. MethodsWe report six pediatric patients who underwent SLAN for uncomplicated appendicitis from April to November 2019. SLAN was performed transumbilically, while conventional laparoscopic instruments and needle-type grasping forceps were both used. After routine intracorporeal appendectomy was completed, the pathological appendix was extracted through the single-port site, while a 10 mm trocar was used to avoid incision infectious. Clinical data and postoperative follow-up data were collected and analyzed to evaluate the feasibility, safety, and clinical outcomes of this novel technique. ResultsSLAN was successfully performed in all six pediatric patients. The median operative time, first exhaust time after surgery, pain score of postoperative day 1, and postoperative hospital stay were 69 (range, 50−85) min, 1.33 (range, 1–2) d, 0.83 (range, 0–3) score, 1.5 (range, 1–2) d, respectively. Neither intraoperative nor postoperative complications were noted, while no incision infectious, adhesive intestinal obstruction, and abdominal abscess were observed with 2–9 months follow up. DiscussionThough there are many methods to perform single-port laparoscopic appendectomy, the use of needle grasping forceps in laparoscopic appendectomy has been confirmed a new choice for uncomplicated appendicitis in children. ConclusionSLAN is a feasible and safe technique to treat acute uncomplicated appendicitis in children. To be emphasized, surgeons must strictly grasp the indications for this surgery.