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AlRamahi RW, Woerner A, Rizvi H, Monroe EJ. Complicated appendicitis in the pediatric patient: interventional perspectives. Clin Imaging 2025; 118:110371. [PMID: 39616878 DOI: 10.1016/j.clinimag.2024.110371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2024] [Revised: 11/20/2024] [Accepted: 11/22/2024] [Indexed: 01/13/2025]
Abstract
This pictorial review provides a comprehensive visual and textual overview of interventional radiology approaches in treating complicated appendicitis and other abdominal abscesses in children. This review discusses the incidence and complications associated with appendicitis in pediatric patients, highlighting the role of percutaneous drainage in managing appendicitis with abscesses. We present common mimics of intra-abdominal abscesses from other diseases such as tubo-ovarian abscesses, inflammatory bowel disease, and lymphomatous bowel involvement, emphasizing imaging pitfalls that can mimic appendiceal abscesses. The review also covers interventional radiology considerations, including antibiotic indications, local anesthesia considerations for children, the comparison between percutaneous and endocavitary approaches, and the roles of fibrinolytics are discussed here. Detailed discussions on catheter selection and insertion techniques, such as Seldinger and trocar, are provided along with post-procedure management strategies. These include drain maintenance, navigating drain associated complications, and determining when to remove the drain. Through high-quality images and concise descriptions, we illustrate procedural intricacies and clinical scenarios encountered in practice, offering a valuable educational resource for clinicians managing pediatric abscesses.
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Affiliation(s)
- Ronnie W AlRamahi
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, United States of America.
| | - Andrew Woerner
- Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA 98195, United States of America
| | - Hassan Rizvi
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, United States of America
| | - Eric J Monroe
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, United States of America
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2
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Cao X, Geng X, Zhang C, Chen J, Zhang C, Liu Q, Wu T, Li L. Effect of instant surgery compared with traditional management on paediatric complicated acute appendicitis post-surgery wound: A meta-analysis. Int Wound J 2023; 20:2964-2972. [PMID: 36965159 PMCID: PMC10502279 DOI: 10.1111/iwj.14163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 02/27/2023] [Accepted: 03/07/2023] [Indexed: 03/27/2023] Open
Abstract
A meta-analysis study to assess the influence of instant surgery (IS) compared with conservative therapy (CT) on paediatric complicated acute appendicitis (CAA) post-surgery wounds. A comprehensive literature examination until January 2023 was implemented, and 2098 linked studies were appraised. The picked studies contained 66 674 subjects with paediatric CAA post-surgery wounds in the picked studies' baseline; 64 643 of them were using IS, and 2031 were using CT. The odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to calculate the consequence of the IS compared with the CT on paediatric CAA post-surgery wounds using the dichotomous and continuous styles and a fixed or random model. The IS had a significantly higher wound infection (OR, 4.97; 95% CI, 2.35-10.54, P < .001) with moderate heterogeneity (I2 = 57%) compared with the CT in a paediatric CAA post-surgery wound. However, no significant difference was found between IS and CT in total antibiotic duration (MD, -5.34; 95% CI,-12.67 to -1.98, P = .15) with high heterogeneity (I2 = 95%) in paediatric CAA post-surgery wounds. The IS had a significantly higher wound infection; however, no significant difference was found in total antibiotic duration compared with the CT in paediatric CAA post-surgery wounds. Although precautions should be taken when commerce with the consequences because most of the studies picked for this meta-analysis had low sample sizes.
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Affiliation(s)
- Xiansheng Cao
- Department of Gastrointestinal Surgery, Hernia and Abdominal Wall Surgery ⅠYantai Affiliated Hospital of Binzhou Medical UniversityShandongChina
| | - Xuejing Geng
- Department of PediatricsYantai Affiliated Hospital of Binzhou Medical UniversityShandongChina
| | - Chunlei Zhang
- Department of Colorectal and Anus SurgeryYantai Affiliated Hospital of Binzhou Medical UniversityShandongChina
| | - Jun Chen
- Department of Gastrointestinal Surgery, Hernia and Abdominal Wall Surgery ⅠYantai Affiliated Hospital of Binzhou Medical UniversityShandongChina
| | - Chao Zhang
- Department of Gastrointestinal Surgery, Hernia and Abdominal Wall Surgery ⅠYantai Affiliated Hospital of Binzhou Medical UniversityShandongChina
| | - Qi Liu
- Department of Gastrointestinal Surgery, Hernia and Abdominal Wall Surgery ⅠYantai Affiliated Hospital of Binzhou Medical UniversityShandongChina
| | - Tianyu Wu
- Department of Gastrointestinal Surgery, Hernia and Abdominal Wall Surgery ⅠYantai Affiliated Hospital of Binzhou Medical UniversityShandongChina
| | - Lei Li
- Department of Gastrointestinal Surgery, Hernia and Abdominal Wall Surgery ⅠYantai Affiliated Hospital of Binzhou Medical UniversityShandongChina
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Liao J, Zhou J, Wang J, Xie G, Wei H. Prophylactic abdominal drainage following appendectomy for complicated appendicitis: A meta-analysis. Front Surg 2023; 9:1086877. [PMID: 36743896 PMCID: PMC9889918 DOI: 10.3389/fsurg.2022.1086877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/28/2022] [Indexed: 01/19/2023] Open
Abstract
Background To date, the value of prophylactic abdominal drainage (AD) following appendectomy in patients with complicated appendicitis (CA), including adults and children, has yet to be determined. This paper presents a meta-analysis of the effects of prophylactic AD on postoperative complications in patients with CA, with the goal of exploring the safety and effectiveness of prophylactic AD. Methods PubMed, Science Direct, Web of Science, Cochrane Library, and Embase databases were searched for relevant articles published before August 1, 2022. The primary outcomes were the complication rates [overall incidence of postoperative complications, incidence of intra-abdominal abscess (IAA), wound infection (WI), and postoperative ileus (PI), and the secondary outcome was the perioperative outcome]. The meta-analysis was performed with STATA V. 16.0A. Results A total of 2,627 articles were retrieved and 15 high-quality articles were eventually included after screening, resulting in a total of 5,123 patients, of whom 1,796 received AD and 3,327 did not. The results of this meta-analysis showed that compared with patients in the non-drainage group, patients in the drainage group had longer postoperative length of hospitalization (LOH) (SMD = 0.68, 95% CI: 0.01-1.35, P = 0.046), higher overall incidence of postoperative complications (OR = 0.50, 95% CI: 0.19-0.81, P = 0.01), higher incidence of WI (OR = 0.30, 95% CI: 0.08-0.51, P = 0.01) and PI (OR = 1.05, 95% CI: 0.57-1.54, P = 0.01), the differences were statistically significant. However, there was no significant difference in the incidence of IAA (OR = 0.10, 95% CI: -0.10 to 0.31, P = 0.31) between the two groups. The results of subgroup meta-analysis showed that in the adult subgroup, the overall incidence of postoperative complications in the drainage group was higher than that in the non-drainage group (OR = 0.67, 95% CI: 0.37-0.96, P = 0.01). However, there were no significant differences in IAA (OR = 0.18, 95% CI: -0.28 to 0.64, P = 0.45) and WI (OR = 0.13, 95% CI: (-0.40 to 0.66, P = 0.63) and PI (OR = 2.71, 95% CI: -0.29 to 5.71, P = 0.08). In the children subgroup, there were no significant differences in the incidence of IAA (OR = 0.51, 95% CI: -0.06 to 1.09, P = 0.08) between the two groups. The overall incidence of postoperative complications (OR = 0.46, 95% CI: 0.02-0.90, P = 0.04), incidences of WI (OR = 0.43, 95% CI: 0.14-0.71, P = 0.01) and PI (OR = 0.75, 95% CI: 0.10-1.39, P = 0.02) were significantly higher than those in the non-drainage group. Conclusion This meta-analysis concluded that prophylactic AD did not benefit from appendectomy, but increased the incidence of related complications, especially in children with CA. Thus, there is insufficient evidence to support the routine use of prophylactic AD following appendectomy.
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Lloyd K, Petrosyan M, Hamdy RF. Appendicitis. PRINCIPLES AND PRACTICE OF PEDIATRIC INFECTIOUS DISEASES 2023:437-441.e4. [DOI: 10.1016/b978-0-323-75608-2.00065-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Abstract
Appendicitis is one of the most common surgical emergencies in children and adults. Appendectomy as the standard care has been challenged in the recent years with growing evidence about non-operative treatment as a potential primary treatment in patients presenting with signs and symptoms suggestive of acute appendicitis. This review aims to establish where the recent research stands regarding conservative treatment of acute appendicitis, especially in children. There are several studies that report the potential safety and efficacy of treating acute appendicitis non-operatively. Several studies have challenged the concept of acute appendicitis being a progressive disease that always ends in perforation, rather than a disease that can present as different forms with only a defined number of cases progressing to perforation. The lack of randomized controlled studies is a limitation and well-designed randomized controlled trials are needed to determine the role of non-operative management of acute appendicitis in children.
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Affiliation(s)
- Soma Jumah
- Unit of Pediatric Surgery, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Tomas Wester
- Unit of Pediatric Surgery, Karolinska University Hospital, 17176 Stockholm, Sweden ,Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
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Camacho-Cruz J, Padilla PO, Sánchez DG, Mongui DM, Hoyos LK, Porras ML, Hoyos PV, Polo F, Castro CA. Outcomes of acute appendicitis in patients younger than age 4: a descriptive study. ANNALS OF PEDIATRIC SURGERY 2022. [DOI: 10.1186/s43159-022-00196-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Acute appendicitis is an infrequent pathology in children under 4 years of age, and its diagnosis is a clinical challenge that can lead to late detection. The intention of this study is to describe the clinical and surgical findings and to explore factors and outcomes associated with appendiceal perforation in patients under 4 years of age with histologically confirmed acute appendicitis. Cross-sectional study of historical data is on patients with a pathologic diagnosis of appendicitis. Clinical, surgical, and pathological variables were described. The relationship between the presence of perforation and associated factors and outcomes was explored using odds ratios (OR) and 95% confidence intervals.
Results
Seventy-five patients were found between 2013 and 2019. Seventy-four cases presented with pain on palpation, 56 (75%) with signs of peritoneal irritation, and 70 (93%) with sepsis on admission to the emergency room. An ultrasound was done on 57 patients (76%), and only 26 (45%) were suggestive of appendicitis. Forty-one (55%) cases were operated on by open surgery and 34 (45%) by laparoscopy. In 61 (81%), they were perforated, and 48 (64%) presented peritonitis. Perforation was associated with increased hospital days (OR = 2.54 [1.60−4.03]), days of antibiotics (OR = 4.40 [2.09−9.25]), and admission to intensive care (OR = 9.65 [1.18−78.57]).
Conclusions
Abdominal pain reported by parents, pain on abdominal palpation, and clinical criteria of sepsis on admission to the emergency room are common features. Acute appendicitis complicated by perforation leads to high morbidity due to longer antibiotic treatment, hospitalization days, admission to PICU, and postoperative ileus.
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Pennell C, Meckmongkol T, Prasad R, Ciullo S, Arthur Iii LG, Lindholm E, Grewal H. A Standardized Protocol for Nonoperative Management of Complicated Appendicitis in Children Reduces Resource Utilization. Eur J Pediatr Surg 2021; 31:14-19. [PMID: 32829480 DOI: 10.1055/s-0040-1715439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION To standardize care and reduce resource utilization, we implemented a standardized protocol (SP) for the nonoperative treatment of complicated appendicitis. MATERIALS AND METHODS We conducted a prospective, historically controlled, study of patients <21 years with complicated appendicitis managed nonoperatively using an SP from January 2017 to November 2018. The primary outcomes included length of stay (LOS), antibiotic days, peripheral inserted central catheter (PICC) utilization, discharge on intravenous antibiotics, and predischarge imaging. Secondary outcomes were protocol adherence and the rates of adverse events (AE) including return to emergency department (ED), readmission, failure of nonoperative treatment, and interval appendectomy complications. RESULTS Protocol adherence was 67.9%. In total, 741 children were treated for appendicitis of which 58 (30 pre-SP and 28 post-SP) were treated nonoperatively for complicated appendicitis at presentation. Patients were well matched for age, admission white blood cell, sex, body mass index, race, and the proportion requiring percutaneous drainage. After implementing the SP, fewer children had PICCs (100.0 vs. 57.1%, p ≤ 0.001), fewer were discharged on intravenous antibiotics (90.0 vs. 42.9%, p < 0.001), and total antibiotic days were reduced (14.0 vs. 10.0, p = 0.006). There was no difference in LOS (5.5 vs. 6.0 days, p = 0.790) or the proportion undergoing ultrasound (36.7 vs. 39.3%, p = 0.837) or computed tomography scan (16.7 vs. 3.6%, p = 0.195) prior to discharge. There were nonsignificant trends toward reduced AEs (46.7 vs. 35.7%, p = 0.397), returns to ED (40.0 vs. 28.6%, p = 0.360), and readmissions (26.7 vs. 17.9%, p = 0.421). The proportion failing nonoperative treatment (10.0 vs. 3.6%, p = 0.612) and experiencing complications of interval appendectomy (3.3 vs. 3.6%, p = 0.918) were not significantly different. CONCLUSION Implementing an SP for treating complicated appendicitis nonoperatively reduced resource utilization without negatively affecting clinical outcomes.
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Affiliation(s)
- Christopher Pennell
- Department of Pediatric General, Thoracic, and Minimally Invasive Surgery, Saint Christopher's Hospital for Children, Philadelphia, Pennsylvania, United States
| | - Teerin Meckmongkol
- Department of Pediatric General, Thoracic, and Minimally Invasive Surgery, Saint Christopher's Hospital for Children, Philadelphia, Pennsylvania, United States
| | - Rajeev Prasad
- Department of Pediatric General, Thoracic, and Minimally Invasive Surgery, Saint Christopher's Hospital for Children, Philadelphia, Pennsylvania, United States.,Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States
| | - Sean Ciullo
- Department of Pediatric General, Thoracic, and Minimally Invasive Surgery, Saint Christopher's Hospital for Children, Philadelphia, Pennsylvania, United States.,Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States
| | - Lindsay Grier Arthur Iii
- Department of Pediatric General, Thoracic, and Minimally Invasive Surgery, Saint Christopher's Hospital for Children, Philadelphia, Pennsylvania, United States.,Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States
| | - Erika Lindholm
- Department of Pediatric General, Thoracic, and Minimally Invasive Surgery, Saint Christopher's Hospital for Children, Philadelphia, Pennsylvania, United States
| | - Harsh Grewal
- Department of Pediatric General, Thoracic, and Minimally Invasive Surgery, Saint Christopher's Hospital for Children, Philadelphia, Pennsylvania, United States.,Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States
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Takahashi Y, Obata S, Matsuura T, Kawano Y, Yanagi Y, Yoshimaru K, Izaki T, Taguchi T. The experiences of interval appendectomy for inflammatory appendiceal mass. Pediatr Int 2021; 63:88-93. [PMID: 32568432 DOI: 10.1111/ped.14358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/23/2020] [Accepted: 06/17/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Interval appendectomy (IA) is a common treatment of acute appendicitis (AA) with inflammatory appendiceal mass (IAM). However, the management of patients with IAM is still controversial. The aim of this study was to assess the outcomes in patients with this condition. METHODS We retrospectively evaluated 244 patients with AA for their clinical characteristics and outcomes. RESULTS Forty-three patients had IAM at the first medical examination. The mean age was significantly younger and the C-reactive protein level significantly higher (12.6 vs 3.1 mg/dL) in patients with IAM. Thirty-four patients received IA, and nine received emergency appendectomy (EA). In the IA group, the diameter of the abscess was larger than in the EA group (31.4 vs 16.1 mm). The total length of hospitalization was longer in the IA group than the EA group (20.6 vs 7.0 days), although the operative time was longer in the EA group because of adhesion (101.1 vs 192.1 min). Furthermore, most IA patients received a reduced-port appendectomy (74% vs 11%). Recurrence occurred in approximately 15% of patients awaiting IA. There were no complications in either group. CONCLUSIONS Although each treatment approach has its advantages and disadvantages, both IA and EA can be the first option for the treatment of AA with IAM.
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Affiliation(s)
- Yoshiaki Takahashi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Satoshi Obata
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshiharu Matsuura
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuki Kawano
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yusuke Yanagi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koichiro Yoshimaru
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoko Izaki
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoaki Taguchi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Pediatric appendectomy in developing countries: How does it differ from international experience? Int J Pediatr Adolesc Med 2020; 7:70-73. [PMID: 32642539 PMCID: PMC7335814 DOI: 10.1016/j.ijpam.2019.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 06/25/2019] [Indexed: 11/20/2022]
Abstract
Introduction A review of the English literature indicates the faint superiority of laparoscopic (LA) over open appendectomy (OA) in the pediatric population; however, a developing-country's experience in the field is not available yet. This study presents our experience in LA versus OA over the last 7 years in one university hospital in Lebanon and compares our results to the international ones. Method A single center retrospective study was done including all patients aged less than 15 years who underwent appendectomy. A description of each operative technique is presented. Patients' characteristics, intraoperative finding, operative timing (OT), length of stay (LOS) and short term postoperative complications including surgical site infection (SSI) rate, intra-abdominal abscess formation (IAA) rate and reoperation rate were all studied. Statistical analysis was done using Chi-square or Fisher's exact test, as for continuous, Student's t test was used or one-way ANOVA in case of more than 2 categories. Result Appendectomy was performed in 84 patients. 52 patients underwent OA through a Rocky Davis incision, and 32 patients underwent a LA. We found an advantage of LA over OA in reducing SSI, otherwise both approaches were similar. Conclusion In accordance with international results, in our experience, LA is superior to OA only with regards to SSI.
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Zavras N, Vaos G. Management of complicated acute appendicitis in children: Still an existing controversy. World J Gastrointest Surg 2020; 12:129-137. [PMID: 32426092 PMCID: PMC7215970 DOI: 10.4240/wjgs.v12.i4.129] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/24/2020] [Accepted: 03/30/2020] [Indexed: 02/06/2023] Open
Abstract
Complicated acute appendicitis (CAA) is a serious condition and carries significant morbidity in children. A strict diagnosis is challenging, as there are many lesions that mimic CAA. The management of CAA is still controversial. There are two options for treatment: Immediate operative management and non-operative management with antibiotics and/or drainage of any abscess or phlegmon. Each method of treatment has advantages and disadvantages. Operative management may be difficult due to the presence of inflamed tissues and may lead to detrimental events. In many cases, non-operative management with or without drainage and interval appendectomy is advised. The reasons for this approach include new medications and policies for the use of antibiotic therapy. Furthermore, advances in radiological interventions may overcome difficulties such as diagnosing and managing the complications of CAA without any surgeries. However, questions have been raised about the risk of recurrence, prolonged use of antibiotics, lengthened hospital stay and delay in returning to daily activities. Moreover, the need for interval appendectomy is currently under debate because of the low risk of recurrence. Due to the paucity of high-quality studies, more randomized controlled trials to determine the precise management strategy are needed. This review aims to study the current data on operative vs non-operative management for CAA in children and to extract any useful information from the literature.
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Affiliation(s)
- Nick Zavras
- Department of Paediatric Surgery, “ATTIKON” University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 12462, Greece
| | - George Vaos
- Department of Paediatric Surgery, “ATTIKON” University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 12462, Greece
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11
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Pathology findings following interval appendectomy: Should it stay or go? J Pediatr Surg 2020; 55:737-741. [PMID: 31130351 DOI: 10.1016/j.jpedsurg.2019.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/01/2019] [Accepted: 05/06/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE Interval appendectomy following nonoperative management of complicated appendicitis remains controversial. The aim of this study was to evaluate surgical pathology and clinical outcomes after pediatric interval appendectomy. METHODS Pathology results from children with complicated appendicitis who underwent interval appendectomy at a single children's hospital from 2010 to 2017 were reviewed. The primary outcome was pathology results. Secondary outcomes included complications and readmission following initial treatment and after interval appendectomy. RESULTS Among 149 patients (median age 11 years; range, 1-18), all had evidence of persistent inflammation on surgical pathology, 25 (17%) had an appendicolith, and no neoplasms were identified. Median duration of the initial admission was 8 days (range, 2-28) and 70% received a percutaneous drain prior to appendectomy. Interval appendectomy was performed at a median of 7.5 weeks (range, 2.9-29.1). Thirty-six (24%) returned to the hospital prior to their scheduled appendectomy and 6 (4%) required appendectomy earlier than planned. Nine patients (6%) experienced a complication following interval appendectomy, of which superficial surgical site infection was the most common (n = 4). CONCLUSION All children had evidence of ongoing inflammation on surgical pathology. While the clinical implications of persistent inflammation remain uncertain, these findings suggest that interval appendectomy is an appropriate treatment following medical management of complicated appendicitis in children. LEVEL OF EVIDENCE SECTION IV, Case series with no comparison groups.
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12
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Watanabe R, Otsuji A, Nakamura Y, Higuchi T, Takahashi A, Saito T, Enomoto T, Quero G, Diana M, Dallemagne B, Marescaux J, Saida Y, Kusachi S. Superior outcomes (but at higher costs) of non-operative management with interval appendectomy over immediate surgery in appendicitis with abscess: Results from a large adult population cohort. Asian J Endosc Surg 2020; 13:186-194. [PMID: 31267689 DOI: 10.1111/ases.12726] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 05/02/2019] [Accepted: 05/20/2019] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The aim of this study was to compare surgical outcomes and hospitalization costs between immediate surgery and non-operative management followed by interval appendectomy in adults presenting with appendicitis with abscess. METHODS From 2003 to 2015, 3316 patients presented with appendicitis, including 101 who presented with appendicular abscess. Between 2003 and 2006, 33 patients with appendicular abscess were managed with emergency operations (emergency group). Non-operative management followed by interval appendectomy was implemented in 2007 and offered to 68 patients during the study period. Of these patients, 64 patients underwent the procedure (interval group), and 4 patients refused. RESULTS Non-operative management was successful in 76.6% of cases (49/64 patients) in the interval group. Operative time and length of hospital stay were similar between the emergency and interval groups. In the interval group, blood loss, the need for extended resection, and overall postoperative morbidity were significantly lower than in the emergency group (P < 0.01, respectively). Medical costs for surgery in the interval group were lower than in the emergency group ($4512 vs $6888, P = 0.002), but this group's total medical costs were higher ($9591 vs $6888, P < 0.01). CONCLUSION The interval strategy is associated with a reduced need for extended resection, lower postoperative morbidity, and a shorter length of hospital stay. However, total medical costs for the interval strategy are higher than those for emergency operations in cases of appendicular abscess in adults.
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Affiliation(s)
- Ryohei Watanabe
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan.,University Hospital Institute (IHU)- Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,Research Institute Against Digestive Cancer (IRCAD), Strasbourg, France
| | - Ayako Otsuji
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yoichi Nakamura
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Tadashi Higuchi
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Asako Takahashi
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Tomoaki Saito
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Toshiyuki Enomoto
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Giuseppe Quero
- University Hospital Institute (IHU)- Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
| | - Michele Diana
- University Hospital Institute (IHU)- Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,Research Institute Against Digestive Cancer (IRCAD), Strasbourg, France
| | | | - Jacques Marescaux
- University Hospital Institute (IHU)- Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,Research Institute Against Digestive Cancer (IRCAD), Strasbourg, France
| | - Yoshihisa Saida
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Shinya Kusachi
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
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Zhou C, Song X, Guo C, Tan Y, Zhao J, Yang Q, Chen D, Tan T, Sun X, Gong T, Zhang Z. Alternative and Injectable Preformed Albumin-Bound Anticancer Drug Delivery System for Anticancer and Antimetastasis Treatment. ACS APPLIED MATERIALS & INTERFACES 2019; 11:42534-42548. [PMID: 31479235 DOI: 10.1021/acsami.9b11307] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Biomimetic design has been extensively investigated. The only FDA-approved biomimetic albumin-bound paclitaxel may not be beneficial to some treated patients due to rapid dissociation upon intravenous infusion and no substantial improvement in the drug's pharmacokinetics or biodistribution. Herein, we developed an alternative and injectable preformed albumin-bound anticancer drug delivery. We combined HSA, Kolliphor HS 15 (HS15), and pirarubicin (THP) via purely physical forces in a thin-film hydration method to obtain an albumin-bound complex of HSA-THP. The lack of any chemical reactions preserves HSA bioactivity, in contrast to the destroyed secondary structure within AN-THP (albumin nanoparticle of THP) for the harsh manipulation during preparation. In vitro, HSA-THP showed a significantly higher cellular uptake efficiency than THP, and the complex was more cytotoxic. In vivo, HSA-THP showed longer half-life than THP. It also exhibited greater tumor accumulation and tumor penetration via gp60- and SPARC-mediated biomimetic transport than THP and AN-THP. As a result, HSA-THP showed strong antitumor and antimetastasis efficacy, with relatively little toxicity. These results suggest the clinical potential of biomimetic tumor-targeted drug delivery.
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Affiliation(s)
- Chuchu Zhou
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy , Sichuan University , No.17, Block 3, Southern Renmin Road , Chengdu 610041 , China
| | - Xu Song
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy , Sichuan University , No.17, Block 3, Southern Renmin Road , Chengdu 610041 , China
| | - Chenqi Guo
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy , Sichuan University , No.17, Block 3, Southern Renmin Road , Chengdu 610041 , China
| | - Yulu Tan
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy , Sichuan University , No.17, Block 3, Southern Renmin Road , Chengdu 610041 , China
| | - Juan Zhao
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy , Sichuan University , No.17, Block 3, Southern Renmin Road , Chengdu 610041 , China
| | - Qin Yang
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy , Sichuan University , No.17, Block 3, Southern Renmin Road , Chengdu 610041 , China
| | - Dan Chen
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy , Sichuan University , No.17, Block 3, Southern Renmin Road , Chengdu 610041 , China
| | - Tiantian Tan
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy , Sichuan University , No.17, Block 3, Southern Renmin Road , Chengdu 610041 , China
| | - Xun Sun
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy , Sichuan University , No.17, Block 3, Southern Renmin Road , Chengdu 610041 , China
| | - Tao Gong
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy , Sichuan University , No.17, Block 3, Southern Renmin Road , Chengdu 610041 , China
| | - Zhirong Zhang
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy , Sichuan University , No.17, Block 3, Southern Renmin Road , Chengdu 610041 , China
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Early appendectomy vs. conservative management in complicated acute appendicitis in children: A meta-analysis. J Pediatr Surg 2019; 54:2234-2241. [PMID: 30857730 DOI: 10.1016/j.jpedsurg.2019.01.065] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/29/2019] [Accepted: 01/29/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND No consensus exists among surgeons regarding the optimal treatment of complicated acute appendicitis in children (CAA). Existing studies present heterogeneity of data and only few studies analyzed free perforated appendicitis (FPA) separately from appendicular abscess (AAb) and appendicular phlegmon (AP). METHOD Studies which have been judged eligible for this systematic review and consequent meta-analysis are those comparing non-operative management (NOM) with operative management (OM) in children with CAA. Studies were subgrouped between those analyzing mixed patients with CAA, those focusing on patients with AAb/AP and those focusing on patients with FPA. RESULTS Fourteen studies fulfilled the inclusion criteria and were included in the meta-analysis with a total of 1288 patients. In the fixed-effects model the complication rate was significantly favorable to the initial NOM arm for the AAb/AP subgroup (RR = 0.07, 95%CI = 0.02-0.27) and to the OM arm for the FPA subgroup (RR = 1.86, 95%CI = 1.20-2.87); the re-admission rate was significantly favorable to the initial NOM arm for the AAb/AP subgroup (RR = 0.35, 95%CI = 0.13-0.93) and to the OM arm for the FPA subgroup (RR = 1.49, 95%CI = 1.49-7.44). There was no statistical heterogeneity for the two subgroups of patients. The costs weren't significantly different between NOM and OM. The length of stay was favorable to OM. The pooled proportion rate of NOM success was 90%, the pooled relapse rate of appendicitis was 15.4%. CONCLUSIONS Children with AAb/AP reported better results in terms of complication rate and re-admission rate if treated with NOM. Conversely children with FPA showed lower complication rate and re-admission rate if treated with OM. LEVEL OF EVIDENCE II.
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15
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Vaos G, Dimopoulou A, Gkioka E, Zavras N. Immediate surgery or conservative treatment for complicated acute appendicitis in children? A meta-analysis. J Pediatr Surg 2019; 54:1365-1371. [PMID: 30115448 DOI: 10.1016/j.jpedsurg.2018.07.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/19/2018] [Accepted: 07/20/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE This study carried out a meta-analysis to compare immediate surgery (IS) with conservative treatment (CT) of complicated acute appendicitis (CAA) in children. METHODS Systematic literature research was performed for relevant studies published from 1969 to date. Trials of IS compared with CT were included. Outcomes of interest were postoperative morbidity and length of hospital stay (LOS). RESULTS Fifteen trials were studied (1.243 patients). CT achieved better rates of any complication type (odds ratio [OR] 0.22, [95% confidence interval (CI): 0.14, 0.38], p = 0.001) and wound infection (OR: 0.40 [95% CI: 0.17, 0.96], p = 0.041). Neither intraabdominal abscess (OR: 1.03 [95% CI: 0.31, 3.37], p = 0.958) nor postoperative ileus (OR: 0.29 [95% CI: 0.06, 1.44], p = 0.130) was affected by the treatment option. The polled difference in LOS showed a trend for shorter LOS in the IS group (standard mean difference [SMD]: 0.25 [95% CI: 0.07, -0.43], p = 0.007). CONCLUSIONS IS was associated with shorter LOS, while overall complication rates and wound infection declined significantly with CT. The development of intraabdominal abscess and postoperative ileus was not affected by the treatment of choice. The heterogeneity of most studies depicts the need for randomized controlled trials (RCTs) to discover safe management of CAA in children. LEVEL OF EVIDENCE III: Type of study: Meta-analysis.
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Affiliation(s)
- George Vaos
- Department of Paediatric Surgery, Attikon University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
| | - Anastasia Dimopoulou
- Department of Paediatric Surgery, Attikon University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Eleana Gkioka
- Second Department of Paediatrics, Athens Medical Center, Athens, Greece
| | - Nick Zavras
- Department of Paediatric Surgery, Attikon University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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16
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Coccolini F, Fugazzola P, Sartelli M, Cicuttin E, Sibilla MG, Leandro G, De' Angelis GL, Gaiani F, Di Mario F, Tomasoni M, Catena F, Ansaloni L. Conservative treatment of acute appendicitis. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:119-134. [PMID: 30561405 PMCID: PMC6502196 DOI: 10.23750/abm.v89i9-s.7905] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Indexed: 12/17/2022]
Abstract
Acute appendicitis has been considered by surgeons a progressive disease leading to perforation for more than 100 years. In the last decades the theories about this concept gained attention, especially in adults. However, appendectomy for acute appendicitis remains the most common urgent/emergent surgical procedure. At present, accumulating evidences are showing the changing in clinical practice towards the non-operative management of several cases of acute appendicitis either non-complicated or complicated. The present review aims to show the literature results regarding the non-operative management of acute appendicitis in non-complicated and in complicated cases.
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Affiliation(s)
- Federico Coccolini
- Emergency, General and Trauma Surgery dept., Bufalini hospital, Cesena, Italy.
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17
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Howell EC, Dubina ED, Lee SL. Perforation risk in pediatric appendicitis: assessment and management. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2018; 9:135-145. [PMID: 30464677 PMCID: PMC6209076 DOI: 10.2147/phmt.s155302] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Perforated appendicitis, as defined by a visible hole in the appendix or an appendicolith free within the abdomen, carries significant morbidity in the pediatric population. Accurate diagnosis is challenging as there is no single symptom or sign that accurately predicts perforated appendicitis. Younger patients and those with increased duration of symptoms are at higher risk of perforated appendicitis. Elevated leukocytosis, bandemia, high C-reactive protein, hyponatremia, ultrasound, and CT are all useful tools in diagnosis. Distinguishing patients with perforation from those without is important given the influence of a perforation diagnosis on the management of the patient. Treatment for perforated appendicitis remains controversial as several options exist, each with its indications and merits, illustrating the complexity of this disease process. Patients may be managed non-operatively with antibiotics, with or without interval appendectomy. Patients may also undergo appendectomy early in the course of their index hospitalization. Factors known to predict failure of non-operative management include appendicolith, leukocytosis greater than 15,000 white blood cells per microliter, increased bands, and CT evidence of disease beyond the right lower quadrant. In this review, the indications and benefits of each treatment strategy will be discussed and an algorithm to guide treatment decisions will be proposed.
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Affiliation(s)
- Erin C Howell
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Emily D Dubina
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA,
| | - Steven L Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA, .,Division of Pediatric Surgery, UCLA Mattel Children's Hospital, Los Angeles, CA, USA,
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18
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Laparoscopic Appendectomy in Children With Perforated Appendicitis: A Meta-Analysis. Surg Laparosc Endosc Percutan Tech 2018; 27:262-266. [PMID: 28472016 DOI: 10.1097/sle.0000000000000411] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The purpose of this meta-analysis was to compare the influence of different surgical procedures on perforated appendicitis in pediatric population. MATERIALS AND METHODS Studies were identified through a computerized literature search of Pubmed, Embase, Ovid, the Cochrane Colorectal Cancer Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials, the Cochrane Library database, and Web of Science. Two reviewers independently assessed the quality of each study and abstracted outcome data. Data were extracted comparing laparoscopic appendectomy (LA) and open appendectomy (OA) in pediatric population with regard to several postoperative variables. We synthesized published data using fixed-effect models, expressing results as relative risk (RR). RESULTS Nine eligible studies were included which came from various medical centers all over the world. Statistically significant differences between "LA" and "OA" groups were found for wound infection (RR=0.88), intra-abdominal abscess (RR=1.38), and bowel obstruction (RR=0.79). CONCLUSIONS Our meta-analysis found that LA is associated with lower incidence of wound infections and bowel obstruction, but the rate of intra-abdominal abscess was higher than OA.
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19
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Hall NJ, Eaton S. Non-operative management of appendicitis in children. Arch Dis Child 2018; 103:498-502. [PMID: 29066523 DOI: 10.1136/archdischild-2017-313267] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/26/2017] [Accepted: 09/27/2017] [Indexed: 12/16/2022]
Abstract
While appendicectomy has been considered the mainstay of treatment for children with acute appendicitis for many decades, there has been a great deal of recent interest in non-operative treatment (NOT) with antibiotics alone. Initial results suggest that many children with appendicitis can indeed be safely treated with NOT and can be spared the surgeon's knife. Many as yet unanswered questions remain, however, before NOT can be considered a realistic and reliable alternative to surgery. This review summaries current knowledge and understanding of the role of NOT in children with appendicitis and outlines and discusses the outstanding knowledge gaps.
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Affiliation(s)
- Nigel J Hall
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK.,University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Simon Eaton
- Developmental Biology and Cancer Programme, UCL Great Ormond Street Institute of Child Health, London, UK
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20
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Aneiros Castro B, Cano I, García A, Yuste P, Ferrero E, Gómez A. Abdominal Drainage After Laparoscopic Appendectomy in Children: An Endless Controversy? Scand J Surg 2018; 107:197-200. [PMID: 29628008 DOI: 10.1177/1457496918766696] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Routine prophylactic abdominal drains after laparoscopic appendectomy for perforated appendicitis in children are still controversial. Throughout the history of surgery, potential benefits of the abdominal drains have been described. However, in recent studies, no benefits were observed and serious complications have been reported. METHODS From January 2000 to December 2013, all charts of the pediatric patients who underwent laparoscopic appendectomy in our tertiary center were revised. The data from 1736 appendectomies were analyzed. We only included those patients with perforated appendicitis treated with early appendectomy (n = 192). Prophylactic drains were established according to the surgeon's preference. The sample was divided into two groups, those with drain (n = 117) and those without drain (n = 75). Demographics, operative findings, and postoperative outcomes were analyzed in both groups. RESULTS Of all patients, 121 were male and 71 were female with a mean age of 7.77 ± 3.4 years. There were not statistically significant differences between the groups in gender (p = 0.82) and mean age (p = 0.31). There were no statistically significant differences between the two groups in the rate of intra-abdominal abscess, wound infection, and bowel obstruction. However, the drainage group has been statistically associated with an increased requirement of antibiotic and analgesic medication, fasting time, operative time, and length of hospital stay. CONCLUSION The prophylactic use of abdominal drainage after laparoscopic appendectomy for perforated appendicitis in children does not prevent postoperative complications and may be associated with negative outcomes. Prospective randomized studies will be necessary to verify this question.
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Affiliation(s)
- B Aneiros Castro
- 1 Department of Pediatric Surgery, Hospital 12 de Octubre, Madrid, Spain
| | - I Cano
- 1 Department of Pediatric Surgery, Hospital 12 de Octubre, Madrid, Spain
| | - A García
- 1 Department of Pediatric Surgery, Hospital 12 de Octubre, Madrid, Spain
| | - P Yuste
- 2 Department of General Surgery, Hospital 12 de Octubre, Madrid, Spain
| | - E Ferrero
- 2 Department of General Surgery, Hospital 12 de Octubre, Madrid, Spain
| | - A Gómez
- 1 Department of Pediatric Surgery, Hospital 12 de Octubre, Madrid, Spain
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21
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Creating diagnostic criteria for perforated appendicitis using cross-sectional imaging. Pediatr Surg Int 2017; 33:1007-1012. [PMID: 28674919 DOI: 10.1007/s00383-017-4121-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2017] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Preoperative determination of perforated versus acute appendicitis can be difficult. We compared CT and MRI performance in diagnosing perforated appendicitis, and created diagnostic criteria. METHODS We retrospectively reviewed all pediatric patients who underwent appendectomy within one day of CT or MRI between 1/1/2013 and 1/16/2016. True diagnosis was determined by pathology report. Findings on CT/MRI were grouped into "hard" findings (abscess, pneumoperitoneum, extruded fecalith, appendiceal wall with visible hole) and "soft" findings (extensive/diffuse inflammation/free fluid, phlegmon). Correlation of white blood cell count (WBC), temperature, peritoneal signs, and symptom duration >72 h with perforation was assessed using logistic regression. Significant correlates were incorporated in clinical criteria. RESULTS 135 patients underwent appendectomy after CT/MRI. Fifty patients underwent MRI and 85 CT. Using hard and/or soft findings, MRI was 86.7% sensitive and 74.3% specific, compared to 68.4% (p = 0.19) and 92.4% (p = 0.025) for CT. WBC > 15, temperature >38.0 °C, and peritoneal signs predicted perforation. Diagnostic accuracy of MRI was highest using imaging findings alone. Accuracy of CT was improved by mandating at least one of the previous three clinical correlates, resulting in 68.4% sensitivity and 93.9% specificity. CONCLUSIONS MRI trended toward more sensitive and CT was more specific for complicated appendicitis. CT specificity is improved by our algorithm.
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22
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Xu J, Adams S, Liu YC, Karpelowsky J. Nonoperative management in children with early acute appendicitis: A systematic review. J Pediatr Surg 2017; 52:1409-1415. [PMID: 28535960 DOI: 10.1016/j.jpedsurg.2017.05.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 04/11/2017] [Accepted: 05/04/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Appendectomy has remained the gold standard treatment of acute appendicitis for more than 100years. Nonoperative management (NOM) has been shown to be a valid treatment alternative for acute uncomplicated appendicitis in adults. A systematic review of available evidence comparing operative management (OM) and NOM in children with acute uncomplicated appendicitis was performed. METHODS Systematic searches of MedLine, Embase, and a clinical trial register (https://clinicaltrials.gov/) were performed in March 2016. Only articles that studied NOM for uncomplicated appendicitis in children were included. Data generation was performed independently by two authors, and quality was assessed using the rating schema by the Oxford Centre for Evidence-Based Medicine. RESULTS 15 articles were selected: four retrospective analyses, four prospective cohort studies, four prospective nonrandomized comparative trials and one randomized controlled trial (RCT). Initial success of the NOM groups (a cure within two weeks of intervention) ranged from 58 to 100%, with 0.1-31.8% recurrence at one year. CONCLUSION Although present literature is scarce, publications support the feasibility of further studies investigating NOM of acute uncomplicated appendicitis in children. Higher quality prospective RCTs with larger sample sizes and robust randomization methods, studying the noninferiority of NOM with antibiotics compared with OM are required to establish its utility. LEVEL OF EVIDENCE This manuscript is a systematic review and thus assigned the lowest evidence used from the manuscripts analyzed which is a Level IV.
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Affiliation(s)
- Jane Xu
- The School of Women's and Children's Health, The University of New South Wales, New South Wales, Australia
| | - Susan Adams
- The School of Women's and Children's Health, The University of New South Wales, New South Wales, Australia; Department of Pediatric Surgery, Sydney Children's Hospital, Randwick, New South Wales, Australia.
| | - Yingrui Cyril Liu
- Department of Pediatric Surgery, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Jonathan Karpelowsky
- Division of Child and Adolescent Health, The University of Sydney, New South Wales, Australia; Department of Pediatric Surgery, The Children's Hospital at Westmead, New South Wales, Australia
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23
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Bachur RG, Lipsett SC, Monuteaux MC. Outcomes of Nonoperative Management of Uncomplicated Appendicitis. Pediatrics 2017; 140:peds.2017-0048. [PMID: 28759405 DOI: 10.1542/peds.2017-0048] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Nonoperative management (NOM) of uncomplicated pediatric appendicitis has promise but remains poorly studied. NOM may lead to an increase in resource utilization. Our objective was to investigate the trends in NOM for uncomplicated appendicitis and study the relevant clinical outcomes including subsequent appendectomy, complications, and resource utilization. METHODS Retrospective analysis of administrative data from 45 US pediatric hospitals. Patients <19 years of age presenting to the emergency department (ED) with appendicitis between 2010 and 2016 were studied. NOM was defined by an ED visit for uncomplicated appendicitis treated with antibiotics and the absence of appendectomy at the index encounter. The main outcomes included trends in NOM among children with uncomplicated appendicitis and frequency of subsequent diagnostic imaging, ED visits, hospitalizations, and appendectomy during 12-month follow-up. RESULTS 99 001 children with appendicitis were identified, with a median age of 10.9 years. Sixty-six percent were diagnosed with nonperforated appendicitis, of which 4190 (6%) were managed nonoperatively. An increasing number of nonoperative cases were observed over 6 years (absolute difference, +20.4%). During the 12-month follow-up period, NOM patients were more likely to have the following: advanced imaging (+8.9% [95% confidence interval (CI) 7.6% to 10.3%]), ED visits (+11.2% [95% CI 9.3% to 13.2%]), and hospitalizations (+43.7% [95% CI 41.7% to 45.8%]). Among patients managed nonoperatively, 46% had a subsequent appendectomy. CONCLUSIONS A significant increase in NOM of nonperforated appendicitis was observed over 6 years. Patients with NOM had more subsequent ED visits and hospitalizations compared with those managed operatively at the index visit. A substantial proportion of patients initially managed nonoperatively eventually had an appendectomy.
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Affiliation(s)
- Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Susan C Lipsett
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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24
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Park HC, Kim MJ, Lee BH. Effect of a Standardized Protocol of Antibiotic Therapy on Surgical Site Infection after Laparoscopic Surgery for Complicated Appendicitis. Surg Infect (Larchmt) 2017. [PMID: 28631985 DOI: 10.1089/sur.2017.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although it is accepted that complicated appendicitis requires antibiotic therapy to prevent post-operative surgical infections, consensus protocols on the duration and regimens of treatment are not well established. This study aimed to compare the outcome of post-operative infectious complications in patients receiving old non-standardized and new standard antibiotic protocols, involving either 5 or 10 days of treatment, respectively. METHODS We enrolled 1,343 patients who underwent laparoscopic surgery for complicated appendicitis between January 2009 and December 2014. At the beginning of the new protocol, the patients were divided into two groups; 10 days of various antibiotic regimens (between January 2009 and June 2012, called the non-standardized protocol; n = 730) and five days of cefuroxime and metronidazole regimen (between July 2012 and December 2014; standardized protocol; n = 613). We compared the clinical outcomes, including surgical site infection (SSI) (superficial and deep organ/space infections) in the two groups. RESULTS The standardized protocol group had a slightly shorter operative time (67 vs. 69 min), a shorter hospital stay (5 vs. 5.4 d), and lower medical cost (US$1,564 vs. US$1,654). Otherwise, there was no difference between the groups. No differences were found in the non-standardized and standard protocol groups with regard to the rate of superficial infection (10.3% vs. 12.7%; p = 0.488) or deep organ/space infection (2.3% vs. 2.1%; p = 0.797). CONCLUSIONS In patients undergoing laparoscopic surgery for complicated appendicitis, five days of cefuroxime and metronidazole did not lead to more SSIs, and it decreased the medical costs compared with non-standardized antibiotic regimens.
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Affiliation(s)
- Hyoung-Chul Park
- Department of Surgery, Hallym University College of Medicine , Anyang, Republic of Korea
| | - Min Jeong Kim
- Department of Surgery, Hallym University College of Medicine , Anyang, Republic of Korea
| | - Bong Hwa Lee
- Department of Surgery, Hallym University College of Medicine , Anyang, Republic of Korea
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25
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Abstract
Appendicitis is a common cause of abdominal pain in children. The diagnosis and treatment of the disease have undergone major changes in the past two decades, primarily as a result of the application of an evidence-based approach. Data from several randomized controlled trials, large database studies, and meta-analyses have fundamentally affected patient care. The best diagnostic approach is a standardized clinical pathway with a scoring system and selective imaging. Non-operative management of simple appendicitis is a reasonable option in selected cases, with the caveat that data in children remain limited. A minimally invasive (laparoscopic) appendectomy is the current standard in US and European children's hospitals. This article reviews the current 'state of the art' in the evaluation and management of pediatric appendicitis.
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Affiliation(s)
- Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA.
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA
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