Acute appendicitis in children: Reexamining indications for conservative treatment - A large prospective analysis.

INTRODUCTION: Conservative antibiotic treatment (CAT) for uncomplicated acute appendicitis (AUA) in children has been proven safe and efficacious. However, as data accumulate, high rates of recurrent appendicitis and subsequent appendectomy have been reported. This prospective longitudinal study evaluated risk-factors for recurrent AUA after CAT in a large cohort, with long-term follow-up. MATERIALS AND METHODS: Children ages 5 to 16 years admitted to the Department of Pediatric Surgery from 2014 through 2018, diagnosed with AUA were eligible for CAT. We recorded their age, appendix outer diameter, white blood cell counts, C-reactive protein and other related signs and symptoms associated with AUA. Clinical and ultrasonographic follow-up was carried out until follow-up data collection ceased according to the study design (2014-2019). RESULTS: The cohort included 646 children who were initially treated successfully with CAT. Among them, 180 (28%) were readmitted for recurrent acute appendicitis during the follow-up period and 138 (21%) eventually had appendectomy. Overall success of 79% for CAT was recorded in this cohort. A multivariable model including; age, sex, appendiceal diameter, WBC and CRP, found the factors of older age, larger outer appendiceal diameter and high WBC counts significantly related to appendectomy during the follow-up period. We offer a decision tree model to predict appendectomy probabilities for patients based on their prognostic measurements. CONCLUSION: CAT in AUA in children should consider older age, larger outer appendiceal diameter and high WBC counts as risk-factors for recurrent AUA and subsequent appendectomy. The proposed decision tree model may help both clinicians and parents before CAT is chosen. LEVEL OF EVIDENCE: Level 2.

Conservative antibiotic treatment for acute uncomplicated appendicitis is feasible.

PURPOSE: Appendectomy versus conservative antibiotic treatment (CAT) for children with acute uncomplicated appendicitis (AUA) remains unresolved, with concerns regarding the practicality of CAT. We analyzed our center's experience with CAT for AUA, using a protocol with strict inclusion, exclusion and treatment criteria. METHODS: Non-randomized, prospective cohort study included all children admitted betwee 2014 and 2016, with clinical and laboratory tests suspicious for AUA. Data collected included clinical signs and symptoms; laboratory, ultrasound and pathology results. Follow-up was conducted through clinic visits, telephone conversations and national registry analysis. RESULTS: Included in CAT: 362 children, 19 underwent appendectomy within 1-2 days. Overall, 75 were readmitted for recurrent acute appendicitis during 22 months (6-43) follow-up. Thirty were treated successfully with antibiotics a second time. The remaining 45 had appendectomy. Overall, 86.8% underwent CAT with no surgery. Histology of all recurrent AUA revealed no perforations. CONCLUSION: We confirm the feasibility of conservative management of AUA in children. A rigorous diagnostic plan with strict inclusion and exclusion criteria will lead to high success rate of CAT with a strong safety profile. CAT does not compete with surgery or render appendectomy unnecessary. It is a safe alternative to surgery in selected cases.

Conservative treatment in uncomplicated acute appendicitis: reassessment of practice safety.

The success rate of conservative treatment for children with uncomplicated appendicitis was prospectively evaluated among 197 children. All who received intravenous antibiotics for 3-5 days, and if symptoms resolved, were discharged home on oral antibiotics for 5 days. Failure rate, symptoms, laboratory signs, and sonographic findings were evaluated for prognostic markers of treatment failure. Children were followed for 18 months. The success rate of conservative treatment was 87%, with shorter hospital stays compared to children who eventually needed surgery (72 [60-84] vs. 84 h [72-126], P = 0.001). Vomiting and/or nausea and intraluminal fluid on sonography were the only prognostic signs of failed treatment (P = 0.028 and P = 0.0001, respectively). After multi-regression analysis, intraluminal fluid was the only prognostic sign for failed treatment (odds ratio = 10.2; 95% CI 3.3-31.8, P = 0.001). Patients who failed conservative treatment were successfully operated without significant morbidity. Pathology findings were compatible with acute or subacute inflammation in 94% of operated AA, with no perforated appendices. CONCLUSION: When applying rigorous criteria for children with uncomplicated appendicitis, a high success rate can be achieved with conservative treatment. Those who fail conservative treatment have a benign medical course without serious complications. Intraluminal fluid may increase risk for conservative treatment failure. What is Known: • Conservative treatment in uncomplicated acute appendicitis is a reasonable alternative to appendectomy. What is New: • Using rigorous criteria for conservative treatment in uncomplicated acute appendicitis is safe and feasible. • Intraluminal fluid should be considered a contraindication to conservative treatment.

A role for conservative antibiotic treatment in early appendicitis in children.

PURPOSE: To evaluate whether antibiotics without surgery is sufficient treatment for children with clinically and ultrasonographically suspected acute appendicitis (AA). METHOD: Children with clinical, laboratory and radiological findings suspicious for AA were evaluated prospectively. Patients with mild clinical signs, without peritonitis were considered for IV followed by oral antibiotics without surgery. RESULTS: From 1 November 2013 through 30 June 2014, 45 children were diagnosed with early, acute appendicitis. Ages ranged from 4 to 15 years (mean 9.3) and 32 (75%) were boys. All had routine, clinical laboratory and ultrasound workup. Forty-two improved with antibiotic treatment and were discharged home within 3-5 days, without surgery. Three of them were operated on within 24 hours, another two underwent appendectomy for recurrent appendicitis: one at 2 weeks and the other 2 months after discharge. There was no more recurrent appendicitis in 6-14-month follow-up. CONCLUSION: Our series of patients with AA treated with antibiotics only are a product of the observation that some children improve with antibiotics alone at a stage in which surgery is still debatable. These results (89% success rate) support the conservative approach in cases of early appendicitis, without increased morbidity in failed cases.

Is there a connection between paediatric acute idiopathic scrotal oedema and intestinal worm infestation?

AIM: Based on our experience with acute idiopathic scrotal oedema (AISO) and observations of the incidence of intestinal worm infestation (IWI), we decided to test the hypothesis that IWI occurs more frequently among children with AISO than it does in the general population. METHODS: A retrospective questionnaire-based study was conducted comparing the frequency of IWI between children who had AISO and a matched control group who had inguinal hernia surgery in our Pediatric Surgery Department during 2003-2009. This second group was chosen to represent the incidence of IWI in the paediatric community in our region. Records of all patients admitted to the Department of Pediatric Surgery for AISO during 2003-2009 were reviewed. RESULTS: Seventeen out of thirty-eight (44.7%) AISO patients had a history of IWI compared with 5/38 (13.1%) in the control group (P= 0.0047). CONCLUSIONS: Our data clearly show that AISO in children is frequently associated with a history of IWI. Although well-documented, prospective studies are needed to establish these findings, we feel that this report provides a reasonable clue to a possible aetiology of AISO.

The impact of early sonographic evaluation on hospital admissions of children with suspected acute appendicitis.

PURPOSE: Early ultrasound (US) evaluation of children with abdominal pain and suspected acute appendicitis (AA) is an important diagnostic tool. Since 2007, US has become part of routine emergency room (ER) work-up performed for suspected pediatric AA in our hospital. METHODS: We retrospectively compared hospital admissions from 2007 to 2008 with those from 2005 to 2006, when most ultrasounds were done after admission to Pediatric Surgery for observation. RESULTS: During the study (2005-2008), 6,511 children came to the ER with acute abdominal pain. Although pediatric ER sonography increased from 28.1% (865/3,079) in 2005-2006 to 51.7% (1,775/3,432) in 2007-2008 (p < 0.0001), hospitalizations decreased from 33 to 30.1% (p = 0.011). Concurrently, ER US for AA increased from 20.8% (639/2,440) to 38.9% (1,336/2,096) (p < 0.0001), admissions for suspected AA decreased from 51.8% (331/639) to 42% (561/1,336) (p < 0.0001). CONCLUSIONS: Sonography led to a significant decline in admissions and better selection of patients who required surgery for AA. Recurrent ER referrals for the same complaint within 2 weeks was very low (2.9%) with no difference between the two study periods (p = 1); none had AA. These findings encourage us to continue early US in children with suspected AA. This effective tool decreases unnecessary hospital stays, investigative procedures, and surgery, while reducing costs.

Gastric emptying time of oral contrast material in children and adolescents undergoing abdominal computed tomography.

OBJECTIVES: : Considering the hazards of pulmonary aspiration of oral contrast material (OCM) during general anesthesia, we investigated the gastric emptying time (GET) of OCM in children and adolescents undergoing abdominal computed tomography (CT). PATIENTS AND METHODS: : Included in the study were 101 consecutive patients ages 3.1 to 17.9 years (mean age 12.2 +/- 3.3 years), who underwent contrast-enhanced abdominal CT for suspected acute appendicitis (n = 90), abdominal trauma (n = 10), or suspected ileus (n = 1). Oral iodinated ioxithalamate was given for bowel opacification. Background data (age, sex, weight, chronic diseases, and medication intake), time of initiation and completion of OCM, and time of CT scanning were recorded. To estimate the GET of OCM, CT images were reviewed to examine whether the stomach was empty or full of OCM at the time of imaging. RESULTS: : The Kaplan-Meier curve showed that 75% of the patients had OCM in the stomach 48 +/- 5.2 minutes after its completion, 50% after 74 +/- 7.9 minutes, and 25% after 135 +/- 32.5 minutes; 1 patient still had OCM after 162 minutes. Except for the length of time taken to drink the contrast material (< or =90 minutes was associated with slower empting of the stomach; log rank, P = 0.03), GET of OCM was not correlated with sex (P = 0.16), age (P = 0.15), weight (P = 0.13), or type of diagnosis (P = 0.41). CONCLUSIONS: : Given the variability of GET of OCM and if clinically feasible, we advocate waiting at least 3 hours between completion of OCM ingestion and general anesthesia induction.

Management of acute appendicitis: an imaging strategy in children.

The pre-operative diagnosis of acute appendicitis (AA) has markedly changed during the last couple of decades due to the advent of modern imaging technology. Nowadays, the use of imaging has dramatically changed the way we approach children admitted to emergency room for abdominal pain with suspected AA. This change is mainly manifested in our diagnostic strategy.

[Spinal anesthesia in premature infants--indications, technical aspects and results].

PURPOSE: To present our experience with spinal anesthesia in premature and former premature infants, and to focus on technical aspects and pitfalls enlightened with increasing experience. METHODS: The perioperative course of all premature and former premature infants below 60 weeks postconceptual age undergoing spinal anesthesia within an 35-month-period was analyzed. Lumbar puncture was performed while the patient was held seated at L4-5 or L5-S1. Anesthetics included hyperbaric tetracaine or bupivacaine, dose 1 mg/kg with adrenaline. The patients were positioned in the reverse Trendelenburg for 2-3 minutes, and later horizontally. RESULTS: Sixty seven infants (gestational age 30.1 +/- 3.6 weeks, postconceptual age 42.9 +/- 3.4, weight 3234 +/- 1165 grams) underwent spinal anesthesia and surgery. Thirty two had other diseases, including congenital heart (12), lung (15) brain pathology (8) and urological findings (6). Sixty five patients underwent hernia repair and two underwent pyloromyotomy. N2O was added in three infants, and two required general anesthesia. All were found to have lower limb motor blockade postoperatively. Intraoperatively, hypoxemia was diagnosed in two infants, short apnea in two cases and bradycardia in one. The apnea and hypoxemia episodes were successfully treated by reverse Trendelenburg positioning and bag and mask ventilation and the bradycardia that did not respond to tactile stimulation was relieved by atropine. Postoperatively, a short episode of apnea and hypoxemia (one patient) and hypoxemia (one patient) responded to free oxygen administration with/without tactile stimulation. Brief bradycardia (three infants) terminated without intervention. Supplementation and postoperative complication rates resembled previous studies. CONCLUSION: Successful spinal anesthesia in premature and former premature infants depends on close attention to preoperative assessment, patient positioning during and immediately after anesthetic induction, drug dosing and perioperative monitoring. A relatively high dose of local anesthetic should be administered.

Spinal anesthesia in 62 premature, former-premature or young infants--technical aspects and pitfalls.

PURPOSE: To highlight technical aspects and pitfalls of spinal anesthesia (SA) in infants. METHODS: The medical history and perioperative course of all infants who underwent SA over a 28-month period were collected (retrospectively in the first 20). RESULTS: Sixty-two infants underwent surgery under SA. Fifty-five were premature and former-premature, postconceptional age 43.3 +/- 5.0 weeks, weight 3261 +/- 1243 g. Of these, 21 had co-existing disease: cerebral (six), cardiac (nine), pulmonary (11) and urological (six). Hyperbaric tetracaine or bupivacaine 1 mg x kg(-1) with adrenaline was administered. Four infants (three premature) required N(2)O supplementation and three needed general anesthesia. The supplementation rate was similar or lower than in previous studies. Postoperatively, all seven were shown to have lower limb motor and sensory blockade. Complications in premature patients included intraoperative hypoxemia (two), apnea (two) and bradycardia (one). Postoperative complications included bradycardia (three), hypoxemia (one) and apnea and hypoxemia (one). The postoperative complication rate was similar to previous studies. CONCLUSION: Successful SA in infants depends on close attention to preoperative assessment, appropriate patient positioning during and after lumbar puncture, drug dosing and intra- and postoperative cardiorespiratory monitoring. A relatively high dose of hyperbaric solution of tetracaine or bupivacaine with adrenaline should be administered.