Nonoperative treatment of acute appendicitis in children

Background/Purpose

Appendicitis is considered by many surgeons to be a surgical emergency for which necessary to avoid perforation of the appendix. Although it has also been treated nonoperatively using antibiotic therapy, experience in such treatment in children with acute appendicitis (AA) is extremely limited. In addition, previous studies on nonoperative treatment (NT) showed it to be a cause of morbidity and mortality. The authors hold that not all appendicitis cases respond to NT because only some of the cases recover. In the present study, 16 of 95 cases with AA were selected for NT according to physical and ultrasound examinations. The clinical and ultrasonographic findings of the cases are presented.

Methods

The medical records of all children with appendicitis treated between August 2003 and March 2006 were retrospectively reviewed . Patients who had history of abdominal pain for less than 24 hours with localized abdominal tenderness and hemodynamic stability underwent NT. Children were treated with parenteral antibiotics (ampicillin with sulbactam, 100 mg · kg⁻¹ · 24 h⁻¹, divided into 3 doses daily, and ornidasole, 20 mg · kg⁻¹ · 24 h⁻¹, divided intro 2 doses daily), intravenous fluid, and nothing by mouth for at least 48 hours.

Results

A total of 136 patients with appendicitis were treated. Of the cases, 95 (70%) were AA, and 41 (30%) had perforated appendicitis. Sixteen (16.8%) cases of AA were selected for NT (12 boys and 4 girls; age range, 5-13 years; mean age, 9 years). The mean anteroposterior diameter of the appendix at the presentation was 7.11 ± 1.01 mm (range, 6-9.5 mm). Ultrasound examination was repeated after 48 hours of treatment. The mean diameter of the appendix was 4.64 ± 0.82 mm (range, 3.6-6.8 mm). The difference was statistically significant (t = 9.63, P < .0001). Nonoperative treatment was successful in 15 (93.7%) of the 16 patients.

Conclusion

Hyperplasia of the appendiceal lymphoid follicle frequently causes luminal obstruction. Antibiotic therapy probably causes regression of lymphoid hyperplasia because of suppression of bacterial infection and prevents ischemia and bacterial invasion in the early stage of appendicitis. We found that some of the patients who had a history of abdominal pain for less than 24 hours with localized abdominal tenderness and hemodynamic stability could be treated nonoperatively.     

Expanding the inclusion criteria for non-operative management of uncomplicated appendicitis: Outcomes and cost

Background

Carefully selected children with early appendicitis may be managed nonoperatively. However, it is unknown whether nonoperative management (NOM) is applicable to all patients with uncomplicated appendicitis. The purpose of this study was to evaluate the outcomes of NOM of uncomplicated appendicitis with expanded inclusion criteria.

小儿复杂性阑尾炎的腹腔镜治疗

目的 对比分析腹腔镜阑尾切除术(laparoscopic appendectomy,LA)和开腹阑尾切除术( open appendectomy,OA)治疗伴有坏疽、穿孔及阑尾周围脓肿的儿童阑尾炎的疗效.方法 回顾性分析614例儿童复杂性阑尾炎患者的临床资料,比较LA组(267例)和OA组(347例)手术时间、住院时间、住院费用及术后并发症的发生率.结果 本组614例患者中无手术死亡发生,LA组有7例中转开腹手术,LA组术后住院时间较OA组短(4.6d比8.1d,P=0.00),Trocar孔或切口感染(5.3％比12.8％,P=0.03)、肠梗阻(5.0％比10.0％,P=0.04)及院内感染发生率(9.7％比18.3％,P=0.04)均较OA组低.术后LA组腹腔脓肿发生率较OA组高(4.1％比1.1％,P=0.04),差异有统计学意义.两组的手术时间及费用之间比较差异无统计学意义(均P＞0.05).结论 LA具有创伤小、恢复快、并发症少、住院时间短等优点,是治疗儿童复杂性阑尾炎一种安全有效的手术方式,但术后腹腔脓肿发生率偏高.     

腹腔镜与开腹手术治疗小儿急性阑尾炎的对比研究

目的：对比腹腔镜与开腹手术治疗小儿复杂急性阑尾炎的临床疗效。方法：2004年1月至2009年1月收治小儿复杂阑尾炎253例,分别行腹腔镜阑尾切除术（laparoscopic appendectomy,LA）123例,开腹阑尾切除术（open appendectomy,OA）130例,比较两组术中出血量、恢复进食时间、术后住院时间、抗生素使用时间及术后并发症。结果：LA组术中出血量、恢复进食时间、腹腔引流管拔除时间、术后住院时间、抗生素使用时间均明显少于OA组,LA组术后切口感染、肠梗阻、腹腔脓肿发生率低于OA组。结论：腹腔镜治疗小儿复杂急性阑尾炎的疗效明显优于开腹手术。     

腹腔镜阑尾切除术在急性和慢性阑尾炎中应用疗效的比较

目的 通过探讨腹腔镜阑尾切除术在治疗急性和慢性阑尾炎中疗效的优缺点,总结腹腔镜阑尾切除术的手术经验.方法 连续收集北京大学人民医院自2008年6月至2009年12月129例阑尾炎患者的资料,比较急性阑尾炎患者腹腔镜与开腹手术的临床效果,以及急性与慢性阑尾炎的腹腔镜治疗效果.结果 对于急性阑尾炎患者,接受腹腔镜手术患者术后住院时间明显少于开腹组[(4.8±2.6)d比(7.0±1.3)d,t=0.679,P=0.006].在接受腹腔镜组阑尾切除术的患者中,急性阑尾炎患者的平均手术时间[(77±33) min比(55±23) min,t=3.431,P＜0.01]、术后首次排气时间[(2.3±1.2)d比(1.4±0.9)d,t=4.665,P＜0.01]、术后首次进食时间[(2.3±1.4)d比(1.2±0.6)d,t=4.517,P＜0.01)]均长于慢性阑尾炎患者.结论 腹腔镜阑尾切除术治疗急性阑尾炎安全可行;与慢性阑尾炎患者相比,急性阑尾炎患者行腹腔镜阑尾切除术可能导致更多的术后腹腔脓肿和小肠梗阻等并发症.     

儿童阑尾炎诊断和治疗12年经验总结

目的　总结儿童阑尾炎临床诊断与治疗12年来的进展。方法　回顾性分析1991年1月至2 0 0 2年12月收治的2 390例儿童阑尾炎的临床病理资料。结果　本组中单纯型2 37例(9 .91% ) ;化脓型1798例(75 .2 3% ) ,合并穿孔5 6 8例(31.5 9% ) ;坏疽型2 12例(8 .81% ) ,合并穿孔15 9例(71 .36 % ) ;梗阻型14 1例(5 .89% ) ;阑尾脓肿192例(7 .4 % ) ,其中手术切除阑尾加脓肿引流2 0例(0. 83% )。本组平均穿孔率为30 . 12 % ,1岁以下17例(41 .4 6 % ) ,1～4岁2 0 1例(44 .96 % ) ,5～10岁4 0 4例(2 8. 17% ) ,10岁以上98例(2 0. 94 % )。本组患者全部治愈出院。结论　单纯型阑尾炎手术比例数与穿孔率呈反比关系,反映手术指征宽严度与诊疗水平的情况。儿童阑尾炎的穿孔率在30 %左右是可以接受的。     

腹腔镜治疗阑尾炎497例

目的:总结腹腔镜阑尾切除术在治疗阑尾炎中的效果。方法:回顾分析经腹腔镜行阑尾切除术497例的临床资料,并与同期剖腹治疗阑尾炎进行比较。结果:497例中63例无法满意处理残端或盲肠壁内阑尾、腹膜外位阑尾而中转开腹。11例腹腔脓肿,9例皮下气肿,6例术后肩背部疼痛,余者无粪瘘、肠粘连、切口感染、阑尾残株炎等术后并发症。结论:经腹腔镜治疗阑尾炎为首选治疗方式。经腹腔镜切除阑尾可取代传统的开腹阑尾切除术。     

腹腔镜与开腹阑尾切除术治疗急性阑尾炎的疗效分析

目的 比较腹腔镜阑尾切除术(laparoscopic appendectomy,LA)和开腹阑尾切除术(open appendectomy,OA)治疗急性阑尾炎的结果.方法 将2005年5月至2010年5月收治的396例行阑尾切除术的急性阑尾炎病人按手术方法分为LA组和OA组,比较分析两组病人的临床资料.结果 LA组与...     

Pancreatic injury in children: good outcome of nonoperative treatment

Purpose

Treatment of blunt injury of the pancreas in children remains controversial. Some prefer nonoperative treatment, whereas others prefer operative management in selected cases. This report reviews the treatment of patients with blunt pancreatic trauma admitted to a level I pediatric trauma center in The Netherlands.

Methods

Medical records of all children less than 15 years with blunt pancreatic trauma admitted to the University Medical Center St Radboud in the period 1975 to 2003 were retrospectively analyzed.

Results

Thirty-four children were included, age 3 to 14 years. Most injuries were because of bicycle accidents (58%). On admission, amylase was raised in 90% of the patients. Five patients had pancreatic duct injuries identified by imaging (endoscopic retrograde cholangiopancreaticography was used once, magnetic resonance cholangiopancreaticography twice) or at surgery. Thirty-one children were initially managed nonoperatively. Pancreatic surgery was performed in 3 children (1 Roux-Y, 2 drainage only). Mean hospital stay was 29 days in the operative group and 24 days in the nonoperative group. Fluid collections developed in 2 operated patients. Both resolved spontaneously. In 14 of the 31 nonoperated patients, a pseudocyst developed. Only 6 of these needed secondary intervention. Of these, 3 were drained percutaneously. There was no mortality and no long-term morbidity in both groups.

Conclusions

Nonoperative management of pancreatic injury in children has good clinical outcome. Only 10% need secondary surgery. In 50%, pseudocysts develop of which half can be managed nonoperatively. The reliability of computed tomographic scan grading is of limited value to decide whether to operate primarily. There is little to gain with ERCP and stenting. The place of MRCP as a noninvasive diagnostic tool remains to be determined.     

Pediatric laparoscopic appendectomy for acute appendicitis

Background: The benefit of laparoscopy in the treatment of pediatric acute appendicitis continues to be controversial, particularly as it relates to operative time and costs. Methods: We reviewed the charts of 200 children who underwent appendectomy for acute appendicitis concurrently over 35 months at a large teaching childrens hospital. Results: Laparoscopic (n = 106) and open (n = 95) appendectomies were performed. The operative times and postoperative lengths of hospital stay were similar for the two groups. The mean total hospital cost for the laparoscopic group ($5,572) was significantly higher than for the open group ($4,472); (p < 0.01). Conclusions: Notably, the results show similar operative times for laparoscopic and open appendectomy. The cost of laparoscopic appendectomy for acute appendicitis is higher than for the open procedure. This study challenges health care providers to reduce costs and develop new ways to measure beneficial outcomes in a pediatric population that may reveal laparoscopic benefits. Presented on 16 March 2002 at the SAGES Annual Scientific Session and 8th World Congress in New York, NY     

腔镜阑尾切除术与开腹阑尾切除术的临床对比研究

目的 比较腹腔镜阑尾切除术与开腹阑尾切除术的临床治疗效果。方法 采用我院2008年1月至2011年6月间腹腔镜阑尾切除术的患者62例与传统开腹阑尾切除术102例做对比,比较两者在手术时间、术后胃肠功能恢复时间、住院时间和术后并发症等方面的发生率有无显著性差异。结果 两者在术后胃肠功能恢复时间、住院时间和术后并发症发生率上有显著性差异。结论 腹腔镜阑尾切除术相对于开腹阑尾切除术,术后胃肠功能恢复时间快,住院时间短,术后并发症少。     

捏提试验在急性阑尾炎诊断中的价值

目的探讨捏提试验在急性阑尾炎诊断中的价值。方法2008年1月至2010年12月拟诊急性阑尾炎并行阑尾切除术的病人323例,体检时均行捏提试验、Rovsing征及Markle征,分别计算特异性、敏感度及阳性预测值;并比较捏提试验阳性和阴性病人之间阴性阑尾切除率。结果捏提试验的特异性和敏感度分别为80．9％和75．7％;捏提试验的阳性预测值为95．9％,高于Rovs—ing征（87．3％）及Markle征（92．0％）;捏提试验阳性病人的阴性阑尾切除率为4．1％,捏提试验阴性病人的阴性阑尾切除率为36．2％,两者比较,差异有统计学意3L（X^2=43．46,P〈0．05）。结论应用捏提试验能提高急性阑尾炎的诊断率,显著降低阴性阑尾切除率。     

Neutrophil-to-lymphocyte ratio predicts acute appendicitis and distinguishes between complicated and uncomplicated appendicitis: A systematic review and meta-analysis

Objectivesto investigate whether Neutrophil-to-lymphocyte ratio (NLR) can predict acute appendicitis and whether it can distinguish between uncomplicated and complicated appendicitis.MethodsA search of electronic information sources was conducted to identify all studies reporting NLR in patients with clinical suspicion or confirmed diagnosis of acute appendicitis. We considered two comparisons:1) appendicitis versus no appendicitis; 2) uncomplicated appendicitis versus complicated appendicitis. ROC curve analysis was performed to determine cut-off values of NLR for appendicitis and complicated appendicitis.ResultsSeventeen studies, enrolling 8,914 patients were included. NLR of 4.7 was cut-off value for appendicitis with sensitivity of 88.89% and specificity of 90.91% with AUC of 0.96. NLR of 8.8 was cut-off value for complicated appendicitis with sensitivity of 76.92% and specificity 100% with AUC of 0.91. NLR >4.7 was predictor of acute appendicitis (OR:128,P < 0.0001) and, NLR >8.8 was predictor of complicated appendicitis (OR:43,P < 0.0001).ConclusionsNLR predicts both diagnosis and severity of appendicitis. This may have implications for prioritising cases for surgery, for monitoring conservatively treated patients and for patients who do not routinely undergo CT scan (pregnant or paediatric patients).     

根部穿孔性阑尾炎的腹腔镜治疗策略

目的:探讨腹腔镜阑尾切除术(laparoscopic appendectomy,LA)治疗根部穿孔性阑尾炎的可行性,并提出根部穿孔性阑尾炎的临床分型及处理方法。方法:总结2012年9月至2016年3月收治的124例行LA的根部穿孔性阑尾炎患者的临床资料。根据阑尾根部、回盲部能否充分显露及阑尾根部距盲肠壁完整段的长度,将根部穿孔性阑尾炎分为Ⅰ型(Ⅰa型、Ⅰb型、Ⅰc型)、Ⅱ型,其处理方式为:用可吸收结扎夹对系膜缘侧双重夹闭阑尾根部、间断缝合阑尾残端周围5 mm盲肠壁、距阑尾根部10 mm处用腔内切割吻合器闭合并切割阑尾周围盲肠壁组织及中转开腹。结果:124例患者均痊愈出院,包括Ⅰa型73例、Ⅰb型30例、Ⅰc型18例(早期3例中转开腹,后期15例行LA)、Ⅱ型3例。术后病理均证实根部穿孔性阑尾炎。放置腹腔乳胶引流管的患者,术后48~72 h行腹腔B超检查证实无积液后拔除。随访3~48个月,无粘连性肠梗阻、腹腔脓肿及阑尾残端漏发生。结论:LA治疗根部穿孔性阑尾炎是可行的,必须依据临床分型进行根部处理,腔内切割吻合器处理根部穿孔性阑尾炎具有一定的临床意义。     

Young children with perforated appendicitis benefit from prompt appendectomy

Background/PurposeTo identify factors associated with nonoperative treatment failure in pediatric perforated appendicitis compared to immediate appendectomy.MethodsAfter IRB approval, between September 2016 and August 2017, prospective data were recorded for children (age: 1–18 years) with completed appendectomies and pathologist-confirmed perforations. Children were treated according to clinician-designated preference. Nonoperative treatment was considered failed if a nonresolving obstruction developed or any return of symptoms before the planned interval. The median time from pain onset to treatment initiation was 3 days (range: 1–14). Presentation on days 1 or 2 (early) was compared to day 3 or after(late). The nonoperatives were compared to appendectomies stratified by presentation time. Variables were compared by chi-square, Fisher exact or t-tests. Logistic regression evaluated for independence.ResultsOf 201 suspected perforations, 176 were included, 101 (57%) immediate appendectomies and 75 (43%) nonoperatives. Of 75, 24 (32%) failed; 6 (25%) in hospital, 18 (75%) after discharge. In 51 (68%), nonoperative treatment succeeded. Significantly younger children failed nonoperative treatment (p = 0.03). Failure was independently associated with treatment initiation within 2.75 days from pain onset (OR: 0.07, 95% CI: 0.57–0.98) (p = 0.010) and lower WBC at presentation (OR: 0.03, 95% CI: 0.81–0.98) (p = 0.014). When compared to immediate appendectomy, nonoperatives had more morbidity.ConclusionYounger children fail nonoperative treatment, perforate rapidly and have a significantly lower WBC, but benefit from immediate appendectomy.Level of evidenceTreatment Study Level II.     

桡骨远端骨折--手术与非手术治疗比较

有一些证据表明外科治疗，包括开放复位内固定(ORIF)或经皮穿针固定(不包括Kapandji穿针)，其功能结果优于保守治疗。不过，仍需要大规模的研究和更长的随访来证实这些结论。     

急性非复杂性阑尾炎的治疗选择——病例对照分析

【摘要】 目的〓分析比较单纯抗生素治疗及阑尾切除术在治疗急性非复杂性阑尾炎(AUA)中的疗效及安全性。方法〓符合入组及排除标准的患者分为2组:抗生素组(108例)及手术组(111例)。抗生素组中的患者接受头孢类联合甲硝唑的抗菌方案,手术组中的患者接受阑尾切除术及围手术期抗菌治疗。研究的首要研究指标是治疗疗效,继而分析两组患者间其他临床疗效因素的异同。结果〓手术组的所有患者中手术顺利,治疗成功率为100.0%。抗生素组中治疗成功率为77.8%(84/108)。意向分析研究结果发现两组患者间疗效相差22.2%,在24%的非劣性研究范围内,认为抗生素治疗效果并不劣于手术治疗。研究发现抗生素组的患者在并发症、住院费用、住院期间疼痛VAS评分方面明显优于手术组。结论〓接受抗生素治疗的AUA患者的疗效与阑尾切除的相近,而且接受抗生素治疗的AUA患者疼痛少、恢复快、花费少,结合较低的急性阑尾炎复发率显示抗生素治疗AUA是可行的方法。     

内镜下逆行阑尾炎治疗术疗效及安全性评估

目的 分析内镜下逆行阑尾炎治疗术对急性非复杂性阑尾炎的治疗效果及安全性评估.方法 选取2018年7月至2020年5月佛山市妇幼保健院收治的80例急性非复杂性阑尾炎患者,按治疗方式的不同将其分为常规组(腹腔镜阑尾切除术)和研究组(内镜下逆行阑尾炎治疗术),每组40例.比较两组患者治疗前后的血清肿瘤坏死因子(tumor n...     

迷你腹腔镜阑尾切除术治疗阑尾炎

目的 评价迷你腹腔镜阑尾切除手术新方法。方法 1997年3月至2002年12月应用微型腹腔镜手术器械行阑尾切除36例，并对其临床资料进行分析。结果 手术全部成功。术中出血平均少于5ml，平均手术时间40min，术后不需用止痛剂。住院日2-10(平均4．5)d。术后微切口感染1例，无术后出血及其他并发症。术后3—6个月复查，手术瘢痕消失或不明显。结论 应用微型腹腔镜行阑尾切除手术损伤可达到最小，术后疼痛轻，美容效果显。     

Ultrasound-based decision making in the treatment of acute appendicitis in children

Background/purpose

Imaging techniques are used widely to diagnose appendicitis. However, the negative appendectomy rate remains at about 15%. The authors assessed ultrasound-based decision making in the treatment of acute appendicitis in children.

Methods

The authors prospectively studied 165 consecutive children (3 to 15 years old) evaluated for appendicitis. Diagnosis and treatment were based solely on ultrasound scan findings. Criterion for appendicitis was a diameter exceeding 6 mm. Severity was classified into 4 grades based on the appearance of intramural appendiceal structure. Patients with grades I or II received antibiotic therapy. Patients with grades III or IV underwent appendectomy.

Results

Ultrasound scan diagnosed appendicitis in 93 children (grade I, 7; grade II, 17; grade III, 41; and grade IV, 28). All but 2 patients with grades I or II underwent antibiotic therapy without complication. All grades III or IV patients underwent appendectomy. There was no negative appendectomy among 76 appendectomies during this period. Ultrasound-based prediction of severity was correct in 67 cases (88%). Ultrasonography identified other pathology in 39.

Conclusions

Ultrasonography in children cannot only visualize all inflamed appendices but also predict severity of disease. Treatment based entirely on ultrasound scan identified patients who required surgery for severe appendicitis and permitted successful conservative treatment for mild appendicitis.