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Appendicitis in children

Appendicitis in children. A review of the current literature. Richard Wood Paediatric Surgery Registrar Red Cross Children’s Hospital. Demographics. Most common acute surgical condition Life-time risk: 8.7% in boys; 6.7% in girls[ 1 ]

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Appendicitis in children

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  1. Appendicitis in children A review of the current literature Richard Wood Paediatric Surgery Registrar Red Cross Children’s Hospital

  2. Demographics • Most common acute surgical condition • Life-time risk: 8.7% in boys; 6.7% in girls[1] • Age specific risk: extremely low neonates to peak 12-18 years • Higher family risk in children under 6 years[2] • Rupture rate significantly increased in poorer children[3] 1/Addiss D.G., Shaffer N., Fowler B.S., et al: The epidemiology of appendicitis and appendectomy in the United States.Am J Epidemiol  1990; 132:910-924. 2/Brender J.D., Marcuse E.K., Weiss N.S., et al: Is childhood appendicitis familial?.Am J Dis Child  1985; 139:338-340. 3/Jablonski K.A., Guagliardo M.F.: Pediatric appendicitis rupture rate: A national indicator of disparities in healthcare access.Popul Health Metr  2005; 3:4.

  3. Natural History • Inflammation 2° to luminal obstruction[4] • Fecalith, lymphoid tissue, parasites, foreign body • Fecaliths related to dietary fiber content[5] • Post obstruction mucous accumulation and contained bacterial proliferation • Pressure leads to lymphatic, venous & arterial occlusion. Pressure necrosis and perforation 4/Wangensteen O.H., Dennis C.: Experimental proof of obstructive origin of appendicitis.Ann Surg  1939; 110:629-647. 5/Jones B.A., Demetriades D., Segal I.: The prevalence of appendiceal fecoliths in patients with and without appendicitis: A comparative study from Canada and South Africa.Ann Surg  1985; 202:80-82.

  4. Relapsing /chronic appendicitis[6] • Acute inflammation -› perforation -› abscess • Definition of perforation controversial • <5years perforation 82% • <1year perforation +/- 100% [7] • Wide range for perforation in literature • 20-76% in 30 paediatric hospitals in the US 6/Mattei P., Sola J.E., Yeo C.J.: Chronic and recurrent appendicitis are uncommon entities often misdiagnosed.J Am Coll Surg  1994; 178:385-389. 7/Nance M.L., Adamson W.T., Hedrick H.L.: Appendicitis in the young child: A continuing diagnostic challenge.Pediatr Emerg Care  2000; 16:160-162

  5. Diagnosis • Classic Triad • WBC 11-16000/mm³ significantly higher in cases of perforation[8] • RBC’s, WBC’s and protein common in urine • No evidence CRP superior to WBC count in children – unnecessary expence[9] • Normal WBC and CRP doesn’t exclude Dx [10] 8/Guraya S.Y., Al-Tuwaijri T.A., Khairy G.A., et al: Validity of leukocyte count to predict the severity of acute appendicitis.Saudi Med J  2005; 26:1945-1947. 9/Rodríguez-Sanjuán J.C., Martín-Parra J.I., Seco I., et al: C-reactive protein and leukocyte count in the diagnosis of acute appendicitis in children.Dis Colon Rectum  1999; 42:1325-1329. 10/Gronroos J.M.: Do normal leukocyte count and C-reactive protein value exclude acute appendicitis in children?.Acta Pediatr  2001; 90:649-651.

  6. Scoring systems may be of use • Stratify patients into 3 groups • Surgery (high score) • Imaging (intermediate score) • Discharge (low score) [11] 11/McKay R., Shepherd J.: The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED.Am J Emerg Med  2007; 25:489-493.

  7. Alvarado Score • Abdominal pain that migrates to the right iliac fossa • Anorexia (loss of appetite) or ketones in the urine • Nausea or vomiting • Pain on pressure in the right iliac fossa • Rebound tenderness • Fever of 37.3 °C or more • Leukocytosis, or more than 10000 white blood cells per microliter in the serum • Neutrophilia, or an increase in the percentage of neutrophils in the serum white blood cell count RIF pain and leucocytosis score 2 points each 0-3: Sensitivity no AA 96% -› Discharge 4-6: Sensitivity of AA 36% -› Imaging >7: Sensitivity of AA 78% -› +/- theatre [11]

  8. Radiological imaging • Abdominal X-ray, no benefit except in setting of bowel obstruction and young patients • Ultrasound, safe, non-invasive, radiation and contrast free, but operator dependent • Review of multiple paediatric series (N=5000+) • Sensitivity 78-94% Specificity 89-98%[13] • CT Scan Sensitivity and Specificity 95%[14] • MRI extremely accurate (no radiation) [15] 13/Vignault F., Filiatrault D., Brandt M.L., et al: Acute appendicitis in children: Evaluation with US.Radiology  1990; 176:501-504. 14/Horton M.D., Counter S.F., Florence M.G., et al: A prospective trial of computed tomography and ultrasonography for diagnosing appendicitis in the atypical patient.Am J Surg  2000; 179:379-381. 15/Horman M., Paya K., Eibenberger K., et al: MR imaging in children with nonperforated acute appendicitis: Value of unenhanced MR imaging in sonographically selected cases.AJR Am J Roentgenol  1998; 171:467-470.

  9. Medical Management • Treatment starts with IV fluid and antibiotics • Uncomplicated appendicitis: current evidence suggests single pre-op dose sufficient[16] • Post-op antibiotics indicated in perforation • Duration of treatment determined by resolution of symptoms • CDC guidelines for peritonitis 7-10 days 16/Mui L.M., Ng C.S., Wong S.K., et al: Optimum duration of prophylactic antibiotics in acute non-perforated appendicitis.Aust NZ J Surg  2005; 75:425-428.

  10. Antibiotic regimens • Triple therapy (ampicillin,gentamycin,metronidazole) • Piptaz as effective as triples[17] • Ceftriaxone and metronidazole daily as effective as triples (cost and time benefit)[18] • Early transition to oral antibiotics as effective as prolonged IV’s [19] 17/Nadler E.P., Reblock K.K., Ford H.R., et al: Monotherapy versus multi-drug therapy for the treatment of perforated appendicitis in children.Surg Infect (Larchmt)  2003; 4:327-333. 18/St Peter S.D., Little D.C., Calkins C.M., et al: A simple and more cost-effective antibiotic regimen for perforated appendicitis.J Pediatr Surg  2006; 41:1020-1024. 19/Adibe O.O., Barnaby K., Dobies J., et al: Postoperative antibiotic therapy for children with perforated appendicitis: Long course of intravenous antibiotics versus early conversion to an oral regimen.Am J Surg  2008; 195:141-143.

  11. Surgical Management Acute Appendicitis • Acute appendicitis cured with surgery • Prompt appendicectomy treatment of choice • Appendicitis can be treated with antibiotics alone[20] • Antibiotics change from emergency to elective • Appendicectomy in the middle of the night not justified[21] 20/Styrud J., Eriksson S., Nilsson I., et al: Appendectomy versus antibiotic treatment in acute appendicitis: A prospective multicenter randomized controlled trial.World J Surg  2006; 30:1033-1037. 21/Surana R., Quinn F., Puri P.: Is it necessary to perform appendectomy in the middle of the night in children?.BMJ  1993; 306:1168.

  12. Surgical ManagementPerforated Appendicitis • Appendicectomy in the presence of known perforation is controversial • Antibiotics alone; Antibiotics and interval appendicectomy; Appendicectomy at presentation • Recurrent appendicitis(8-14%) short term [22] • APSA 86% responders perform interval appendicectomy[23] 22/Puapong D., Lee S.L., Haigh P.I., et al: Routine interval appendectomy in children is not indicated.J Pediatr Surg  2007; 42:1500-1503. 23/ Chen C., Botelho C., Cooper A., et al: Current practice patterns in the treatment of perforated appendicitis in children.J Am Coll Surg  2003; 196:212-221.

  13. Surgical ManagementPerforated Appendicitis • Causes of failure of nonoperative management • Band count >15% at presentation[24] • Appendicolith present on imaging[25] • Contamination beyond RIF on imaging[26] • Experienced surgeon should be able to deal with situation at presentation • APSA survey: Senior surgeons base practice on personal preference 24/Kogut K.A., Blakely M.L., Schropp K.P., et al: The association of elevated percent bands on admission with failure and complications of interval appendectomy.J Pediatr Surg  2001; 36:165-168. 25/Aprahamian C.J., Barnhart D.C., Bledsoe S.E., et al: Failure in the nonoperative management of pediatric ruptured appendicitis: Predictors and consequences.J Pediatr Surg  2007; 42:934-938. 26/Levin T., Whyte C., Borzykowski R., et al: Nonoperative management of perforated appendicitis in children: Can CT predict outcome?.Pediatr Radiol  2007; 37:251-255.

  14. Surgical ManagementAbscess at presentation • Open surgery high morbidity • Percutaneous drainage and interval appendicectomy[27] • Long course of treatment, cost burden[28] • Prospective trial currently in progress comparing early laparoscopic surgery with percutaneous drain and delayed surgery[29] 27/Chen C., Botelho C., Cooper A., et al: Current practice patterns in the treatment of perforated appendicitis in children.J Am Coll Surg  2003; 196:212-221. 28/Keckler S.J., St Peter S.D., Tsao K., et al: Resource utilization and outcomes from percutaneous drainage and interval appendectomy for perforated appendicitis.J Pediatr Surg  2008; 43:977-980. 29/ National Institutes of Health: Early versus delayed operation for perforated appendicitis. Available at www.clinicaltrials.gov—NCT# 00414375

  15. Surgical ManagementAbscess at presentation • Regardless of route of drainage cultures not of benefit[30] • One study showed that changing according to cultures had a worse outcome (N=308)[31] • Lavage with saline or antibiotic solution not shown to be of benefit[32] • Post-op intra-peritoneal AB’s may benefit (48h) • Drains only useful in walled off collections[33] 30/Bilik R., Burnweit C., Shandling B.: Is abdominal cavity culture of any value in appendicitis?.Am J Surg  1998; 175:267-270. 31/Kokoska E.R., Silen M.L., Tracy T.F., et al: The impact of intraoperative culture on treatment and outcome in children with perforated appendicitis.J Pediatr Surg  1999; 34:749-753. 32/Sherman J.O., Luck S.R., Borger J.A.: Irrigation of the peritoneal cavity for appendicitis in children: A double blind study.J Pediatr Surg  1976; 11:371-374. 33/Kokoska E.R., Silen M.L., Tracy T.F., et al: Perforated appendicitis in children: Risk factors for the development of complications.Surgery  1998; 124:619-625.

  16. Radiological imaging

  17. Laparoscopic Appendicectomy • Umbilical port and two working ports (open) • Initial data, longer operative time and more intra-abdominal complications in LA[34] • Newer evidence suggests no difference in operative time and IAA in the 2 groups[35] • Risk of abscess formation justification for continued use of open surgery • Substantially lower risk of wound infection[36] 34/Horwitz J.R., Custer M.D., May B.H., et al: Should laparoscopic appendectomy be avoided for complicated appendicitis in children?.J Pediatr Surg  1997; 32:1601-1603. 35/Aziz O., Athanasiou T., Tekkis P.P., et al: Laparoscopic versus open appendectomy in children: A meta-analysis.Ann Surg  2006; 243:17-27. 36/Sauerland S., Lefering R., Neugebauer E.A.: Laparoscopic versus open surgery for suspected appendicitis.Cochrane Database Syst Rev  2004; 18:CD001546

  18. Laparoscopic Appendicectomy • Substantially lower complication rate in obese patients[37] • Shorter duration of hospital stay[36] • Earlier return to work and normal activity[36] • Prospective RCT quality of life, GIT complication and overall complications lower for laparoscopy (N=43757)[38] • Recent Cochrane review: LA 1° operation[36] 36/Sauerland S., Lefering R., Neugebauer E.A.: Laparoscopic versus open surgery for suspected appendicitis.Cochrane Database Syst Rev  2004; 18:CD001546 37/Corneille M.G., Steigelman M.B., Myers J.G., et al: Laparoscopic appendectomy is superior to open appendectomy in obese patients.Am J Surg  2007; 194:877-880. 38/Guller U., Hervey S., Purves H., et al: Laparoscopic versus open appendectomy: Outcomes comparison based on a large administrative database.Ann Surg  2004; 239:43-52.

  19. AppendicitisKey anatomical points

  20. AppendicitisKey anatomical points

  21. Laparoscopic Appendicectomy

  22. Laparoscopic Appendicectomy

  23. Laparoscopic Appendicectomy

  24. Laparoscopic Appendicectomy • Most recent prospective RCT had a mean operation time of 44min in laparoscopic perforated appendicectomy[39] • Evidence heavily in favour of LA 39/St Peter S.D., Tsao K., Spilde T.L., et al: Single daily dosing ceftriaxone and metronidazole vs. standard triple antibiotic regimen for perforated appendicitis in children: A prospective randomized trial.J Pediatr Surg  2008; 43:981-985.

  25. Open Appendicectomy • Transverse incision • Protect wound • Swab out pelvis • Muscle cutting laparotomy in presence of peritonitis

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