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  1. 1. Appendicitis in childrenAppendicitis in children A review of the current literatureA review of the current literature Richard WoodRichard Wood Paediatric Surgery RegistrarPaediatric Surgery Registrar Red Cross Children’s HospitalRed Cross Children’s Hospital
  2. 2. DemographicsDemographics  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. 3. Natural HistoryNatural 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. 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. 5. DiagnosisDiagnosis  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.:
  6. 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 append Am J Emerg Med 2007; 25:489-493.
  7. 7. Alvarado ScoreAlvarado 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. 8. Radiological imagingRadiological 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. 9. Medical ManagementMedical 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. 10. Antibiotic regimensAntibiotic 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 conver
  11. 11. Surgical ManagementSurgical 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. 12. Surgical ManagementSurgical Management Perforated 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. 13. Surgical ManagementSurgical Management Perforated Appendicitis  Causes of failure of nonoperative management 1. Band count >15% at presentation[24] 2. Appendicolith present on imaging[25] 3. 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
  14. 14. Surgical ManagementSurgical Management Abscess 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—NCT# 00414375
  15. 15. Surgical ManagementSurgical Management Abscess 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. 16. Radiological imagingRadiological imaging
  17. 17. Laparoscopic AppendicectomyLaparoscopic 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. 18. Laparoscopic AppendicectomyLaparoscopic 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. 19. AppendicitisAppendicitis Key anatomical points
  20. 20. AppendicitisAppendicitis Key anatomical points
  21. 21. Laparoscopic AppendicectomyLaparoscopic Appendicectomy
  22. 22. Laparoscopic AppendicectomyLaparoscopic Appendicectomy
  23. 23. Laparoscopic AppendicectomyLaparoscopic Appendicectomy
  24. 24. Laparoscopic AppendicectomyLaparoscopic 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. 25. Open AppendicectomyOpen Appendicectomy  Transverse incision  Protect wound  Swab out pelvis  Muscle cutting laparotomy in presence of peritonitis