Laparoscopic <Emphasis Type="Italic">versus</Emphasis> open appendectomy for acute appendicitis in children

Objective

To compare the efficacy and safety of laparoscopic appendectomy and open appendectomy for acute appendicitis in children.

Methods

This study was conducted as a retrospective comparison of hospital records for postoperative complications, duration of operation, and postoperative length of stay between children (aged <18y) who underwent laparoscopic (n=190) or open (n=199) appendectomy over a six-year period. Quality of life was evaluated immediately and 1 month postoperatively.

Results

The major complication rate after surgery in laparoscopic group was significantly lower than that of open appendectomy group (13% vs 27%, P<0.05). The mean (SD) postoperative hospital stay was also shorter in laparoscopic group (2.4 (0.6) days vs 3.7 (1.1) days, P<0.05). The postoperative minor complication rate and hospital expenses were not significantly different between the two groups. The duration of surgery was longer in laparoscopic group (P<0.05). Children in laparoscopic group had less postoperative pain and higher quality of life after one month than those in open appendectomy group.

Conclusions

Laparoscopic technique seems to be safer than open appendectomy for acute appendicitis in children.

     

Imaging in pediatric appendicitis is key to a low normal appendix percentage: a national audit on the outcome of appendectomy for appendicitis in children

Purpose

A laparoscopic approach for emergency appendectomy is increasingly used, in pediatric patients as well. The objective of this study is to audit the current state of diagnostic work-up, surgical techniques and its outcome in children with acute appendicitis.

Methods

A prospective consecutive observational cohort study was carried out in a 2-month study period. All patients under 18 years that were operated for suspected acute appendicitis were included. Primary outcome was the infectious complication rate after open and laparoscopic approach; secondary outcomes were preoperative use of imaging and post-operative predictive value of imaging, normal appendix rate and children with a postoperative ileus.

Results

A total of 541 children were operated for suspected acute appendicitis in 62 Dutch hospitals. Preoperative imaging was used in 98.9% of children. The normal appendix rate was 3.1%. In 523 children an appendectomy was performed. Laparoscopy was used in 61% of the patients and conversion rate was 1.7%. Complicated appendicitis was diagnosed in 29.4% of children. Overall 30-day complication rate was 11.9% and similar after open and laparoscopic. No difference was found in superficial surgical site infections, nor in intra-abdominal abscesses between the open and laparoscopic approach. Complicated appendicitis is an independent risk factor for infectious complications.

Conclusion

The laparoscopic approach is most frequently used, except for young children. Superficial surgical site infections are more frequent after open surgery only in patients with complicated appendicitis. The normal appendix rate is low, most likely because of routine preoperative imaging.

     

A systematic review and individual patient data meta-analysis of published randomized clinical trials comparing early versus interval appendectomy for children with perforated appendicitis

Purpose

Our objective was to perform a meta-analysis on RCTs that compared outcomes in children with perforated appendicitis (PA) who underwent either early appendectomy (EA) or interval appendectomy (IA). We also sought to determine if the presence of an intra-abdominal abscess (IAA) at admission impacted treatment strategy and outcomes.

Methods

We identified two RCTs comparing EA versus IA in children with PA. A meta-analysis was performed using regression models and the overall adverse event rate was analyzed. The treatment effect variation depending on the presence of IAA at admission was also evaluated.

Results

EA significantly reduced the odds of an adverse event (OR 0.28, 95 % CI 0.1–0.77) and an unplanned readmission (OR 0.08, 95 % CI 0.01–0.67), as well as the total charges (79 % of the IA, 95 % CI 63–100) for those who did not have an IAA at admission. In children with an IAA, there was no difference between EA and IA. However, heterogeneity of treatment effect was present regarding IAA at presentation.

Conclusions

While EA appears to improve outcomes in patients without an abscess, the published data support no significant difference in outcomes between EA and IA in patients with an abscess.

     

Empyema Due to Thoracic Migrating Appendicolith

Background

Retained appendicolith following appendicectomy, and can cause recurrent abscess in the abdomen and retroperitoneum.

Case characteristics

11-yr-old boy who presented with subpulmonic abscess and pneumonia following appendicectomy for perforated appendicitis.

Observations

Thoracotomy revealed a thick walled subpulmonic abscess surrounding an appendicolith along with a rent in the posterolateral aspect of the diaphragm.

Message

In children presenting with pus collections and a history of recent appendicectomy, the possibility of a migrating appendicolith should be considered.

     

Effectiveness of gabapentin as a postoperative analgesic in children undergoing appendectomy

Purpose

Though gabapentin is increasingly used as a perioperative analgesic, data regarding effectiveness in children are limited. The purpose of this study was to evaluate gabapentin as a postoperative analgesic in children undergoing appendectomy.

Methods

A 12-month retrospective review of children undergoing appendectomy was performed at a two-hospital children’s institution. Patients receiving gabapentin (GP) were matched (1:2) with patients who did not receive gabapentin (NG) based on age, sex and appendicitis severity. Outcome measures included postoperative opioid use, pain scores, and revisits/readmissions.

Results

We matched 29 (33.3%) GP patients with 58 (66.6%) NG patients (n?=?87). The GP group required significantly less postoperative opioids than the NG group (0.034 mg morphine equivalents/kg (ME/kg) vs. 0.106 ME/kg, p?<?0.01). Groups had similar lengths of time from operation to pain scores?≤?3 (GP 12.21 vs. NG 17.01 h, p?=?0.23). GP and NG had similar rates of revisit to the emergency department (13.8 vs. 10.3%, p?=?0.73), readmission (6.9 vs. 1.7%, p?=?0.26), and revisits secondary to surgical pain (3.4 vs. 3.4%, p?=?1.00).

Conclusion

In this single-center, retrospective cohort study, gabapentin is associated with a reduction in total postoperative opioid use in children with appendicitis. While promising, further prospective validation of clinical effectiveness is needed.

     

Weekend vs. weekday appendectomy for complicated appendicitis,effects on outcomes and operative approach

Purpose

We hypothesized that laparoscopic (LA) or open appendectomy (OA) outcomes in complicated appendicitis are associated with weekend vs. weekday procedure date.

Methods

We queried the Kids’ Inpatient Database (1997–2012) for complicated (540.0, 540.1) appendicitis treated with LA or OA. Propensity score (PS)-matched analysis compared outcomes associated with weekend vs. weekday LA and OA.

Results

Overall, 103,501 cases of complicated appendicitis were identified. On 1:1 PS-matched analyses of complicated appendicitis, weekday OA had increased wound infection rates (odds ratio: 1.3) vs. weekend OA, p?<?0.001. Weekend OA had higher pneumonia rates (1.4) and longer length of stay, but lower home healthcare requirement following discharge vs. weekday OA, p?<?0.05. Weekend and weekday LA had no significant outcome differences.

Conclusion

On a PS-matched comparison of appendectomies performed for complicated appendicitis on weekends and weekdays, procedure day is associated with different complication rates and resource utilization for OA. For LA, no weekend effect was noted for complicated appendicitis. To ensure the optimal patient care, prospective studies should be sought to identify causes of complications dependent on the day of procedure.

     

Emergency surgery for refractory status epilepticus

Background

Management of refractory status epilepticus in children is extremely challenging.

Case characteristics

Two children with medically refractory status epilepticus, both of whom had lesional pathology on MRI and concordant data on EEG and PET scan.

Intervention

Emergency hemispherotomy performed in both patients. A complete, sustained seizure freedom obtained postoperatively.

Message

Emergency surgery is a treatment option in selected cases of drug refractory status epilepticus with lesional pathology and concordant data.

     

Early Neurodevelopmental Outcomes After Corrective Cardiac Surgery In Infants

Objective

To assess neurodevelopmental status in Indian infants undergoing corrective surgery for congenital heart disease (CHD) and to analyze factors associated with neurodevelopmental delay.

Design

Cross-sectional study.

Setting

Tertiary-care pediatric cardiology facility.

Participants

Consecutive infants undergoing corrective surgery for CHD (January 2013–December 2014). Palliative procedures, and patients with known genetic syndromes were excluded.

Main outcome measures

Neurodevelopmental evaluation 3 months, and one year after surgery using Developmental Assessment Scales for Indian Infants (DASII); scores were categorized as delayed if ≤70.

Results

Of the 162 children enrolled, delayed PDI and MDI scores were observed in 33.5% and 19.6% of patients at 3 months, respectively; this reduced to 14.5 % on 1-year follow-up. On multivariate analysis, delayed PDI outcome at one year was predicted by early term birth and one-year postoperative head circumference Z-score <–2. Delayed MDI was associated with higher mean perfusion pressure on cardiopulmonary bypass. Cardiac diagnosis and peri-operative factors did not impact neurodevelopmental outcomes.

Conclusions

Neurodevelopmental status is delayed in 14.5% of infants one year after corrective infant heart surgery.

     

Etiology and Outcome of Cholelithiasis in Turkish Children

Objective

The aim of this study was to examine the etiology of gallstones in children and responses to ursodeoxycholic acid (UDCA) treatment.

Methods

74 children with cholelithiasis were recruited, and underwent ultrasonography to detect gallstones. All relevant clinical information was recorded in a structured proforma.

Results

The commonest risk factor was a family history of gallstones. Most children responded to UDCA treatment in the first six months; children with hemolytic diseases showed no response to UDCA.

Conclusion

UDCA treatment may be useful before surgery in asymptomatic patients of cholelithiasis without hemolytic diseases.

     

The non-visualized appendix and secondary signs on ultrasound for pediatric appendicitis in the community hospital setting

Background

Secondary signs of appendicitis on ultrasound may aid with diagnosis in the setting of a non-visualized appendix (NVA). This role has not been shown in the community hospital setting.

Materials and methods

All right lower quadrant ultrasounds performed in children for clinical suspicion of appendicitis over a 5-year period in a single community hospital were evaluated. Secondary signs of inflammation including free fluid, ileus, fat stranding, abscess, and lymphadenopathy were documented. Patients were followed for 1 year for the primary outcome of appendicitis. These data were analyzed to determine the utility of secondary signs in the diagnosis of acute appendicitis when an NVA is reported.

Results

Six hundred and seventeen ultrasounds were reviewed; 470 of these had an NVA. Of NVAs, 47 (10%) of patients were diagnosed with appendicitis. Sensitivity and specificity of having at least one secondary were 38.3% and 80%, respectively. The positive and negative predictive values of having at least one secondary sign were 17.3% and 92%, respectively.

Conclusion

These data suggest that the absence of secondary signs has a strong negative predictive value for appendicitis in the community hospital setting; however, the full utility of secondary signs may be limited in this setting.

     

Synovial arteriovenous malformation masquerading as arthritis

Background

Synovial arteriovenous malformation is rare.

Case characteristics

We present three children with recurrent monoarthritis secondary to synovial arteriovenous malformation.

Outcome

Two children underwent excision of arteriovenous malformation. Another child had diffuse arteriovenous malformation, which was inoperable.

Message

Synovial arteriovenous malformations should be considered in the differential diagnosis of monoarthritis, especially of the knee.

     

Urinary biomarkers in pediatric appendicitis

Purpose

The diagnosis of pediatric appendicitis is still a challenge, resulting in perforation and negative appendectomies. The aim of this study was to evaluate novel biomarkers in urine and to use the most promising biomarkers in conjunction with the Pediatric Appendicitis Score (PAS), to see whether this could improve the accuracy of diagnosing appendicitis.

Methods

A prospective study of children with suspected appendicitis was conducted with assessment of PAS, routine blood tests, and measurements of four novel urinary biomarkers: leucine-rich α-2-glycoprotein (LRG), calprotectin, interleukin 6 (IL-6), and substance P. The biomarkers were blindly determined with commercial ELISAs. Urine creatinine was used to adjust for dehydration. The diagnosis of appendicitis was based on histopathological analysis.

Results

Forty-four children with suspected appendicitis were included, of which twenty-two (50 %) had confirmed appendicitis. LRG in urine was elevated in children with appendicitis compared to children without (p < 0.001), and was higher in children with gangrenous and perforated appendicitis compared to those with phlegmonous appendicitis (p = 0.003). No statistical significances between groups were found for calprotectin, IL-6 or substance P. LRG had a receiver operating characteristic area under the curve of 0.86 (95 % CI 0.79–0.99), and a better diagnostic performance than all routine blood tests. LRG in conjunction with PAS showed 95 % sensitivity, 90 % specificity, 91 % positive predictive value, and 95 % negative predictive value.

Conclusion

LRG, adjusted for dehydration, is a promising novel urinary biomarker for appendicitis in children. LRG in combination with PAS has a high diagnostic performance.

     

Computed tomography localization of the appendix in the pediatric population relative to the lumbar spine

Background

Computed tomography (CT) is commonly used to evaluate suspected acute appendicitis. Although very effective, CT uses ionizing radiation, exposing patients to an increased risk of cancer.

Objective

This study assessed the potential for decreasing the field of view of the CT (and therefore the dose to the patient) in the evaluation of suspected acute appendicitis in children.

Materials and methods

This study was a retrospective review of prospectively collected data from 212 consecutive patients who underwent CT for suspected acute appendicitis. The most superior aspect of the appendix with respect to vertebral bodies was recorded. Age, gender and diagnosis (negative, acute appendicitis or alternative diagnosis) were noted.

Results

The appendix was visualized in 190 of 212 subjects (89.6%). Overall, all visualized appendixes were located at or below the level of L1. Sixty-three of the subjects (29.7%) were diagnosed with acute appendicitis via CT imaging. All appendixes in patients with acute appendicitis were located at or below the level of the L3 vertebral body, predominating at the level of L5. Six subjects (3.1%) received alternative diagnoses, including pneumonia, pyelonephritis, small bowel obstruction and infected urachal cyst. There were no differences in appendix location with regard to diagnosis, gender, or age (P=0.664, 0.748 and 0.705, respectively).

Conclusion

CT field of view may be decreased to the level of L1 or L3 superiorly, decreasing radiation dose without affecting the rate of appendix visualization.

     

Phlegmonous appendicitis in children is characterized by eosinophilia in white blood cell counts

Background

Phlegmonous and complicated appendicitis represent independent entities depending on hereditary immunological mechanisms. However, clinically there are no means to distinguish uncomplicated phlegmonous from complicated appendicitis. The ability to distinguish these two forms of appendicitis is relevant as current attempts are to treat both forms of the disease differently. The aim of the present study was to investigate differences in white blood cell counts (WBCs) in these conditions to identify areas of interest for future molecular studies.

Methods

White blood cell counts of patients aged between 7 and 14 years who underwent appendectomy from January 2008 to June 2016 were investigated with special reference to particular cellular subpopulations.

Results

A total of 647 children were included in the study. Within distinct inflammatory patterns, significant eosinophilia and basophilia were found in phlegmonous inflammation compared with complicated inflammation (0.11?±?0.19?×?10⁹/L vs. 0.046?±?0.104?×?10⁹/L, P?<?0.0001, and 0.033?±?0.031?×?10⁹/L vs. 0.028?±?0.024?×?10⁹/L, P?<?0.001).

Conclusions

Compared with complicated disease, phlegmonous appendicitis seems to depend primarily on eosinophil inflammation. This observation is stable over time and indicates a direction for investigation of underlying genetic prerequisites.

     

Creating diagnostic criteria for perforated appendicitis using cross-sectional imaging

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.

     

Disseminated cryptococcosis in an immunocompetent toddler

Background

Immunodeficient children are more prone for invasive cryptococcal infections.

Case characteristics

A 2-year-old boy with disseminated cryptococcosis was evaluated for underlying immunodeficiency without success.

Intervention/outcome

Child was managed successfully.

Message

Immunocompetent children with disseminated cryptococcosis can present diagnostic or therapeutic challenge in resource-limited settings.

     

Steroid pulse therapy for Kawasaki disease complicated with myocarditis

Background

The clinical management of intravenous immunoglobulin-resistant Kawasaki disease shock syndrome (KDSS) is obscure.

Case characteristics

Three children presented with intravenous immunoglobulin-resistant KDSS complicated with myocarditis.

Outcome

All cases were successfully managed with steroid pulse therapy.

Message

Steroid pulse therapy is effective in immunoglobulin-resistant KDSS.

     

Hemosuccus pancreaticus

Background

Gastrointestinal bleeding in children has diverse etiologies.

Case characteristics

Two children (age 3y and 7y) with recurrent gastrointestinal bleeding. Computed tomography demonstrated features of chronic pancreatitis but no vessel abnormality. Conventional angiography revealed bleeding from gastroduodenal artery in both cases.

Outcome

Coil embolization of gastroduodenal vessels was performed, and there was no recurrence of bleeding.

Message

Hemosuccus pancreaticus is to be considered in children with chronic pancreatitis presenting with recurrent gastrointestinal bleeding and conventional angiography with coil embolization is helpful.

     

Staged imaging pathway for the evaluation of pediatric appendicitis

Purpose

Despite significant radiation exposure involved with computed tomography (CT) in evaluation of pediatric appendicitis, its use is still widespread. The goal of this study was to assess the effect of a staged imaging pathway for appendicitis to significantly decrease CT use while maintaining diagnostic accuracy.

Methods

Chart review was performed for patients evaluated for appendicitis over a 12-month period prior to and after pathway implementation.

Results

There was a significant decrease in CT use as initial imaging after implementation of the pathway; 87.1–13.4 % for evaluations positive for appendicitis (decrease 84.6 %, p < 0.0001) and 82.6–9.2 % for evaluations negative for appendicitis (decrease 88.9 %, p < 0.0001). Use of CT during any point in the evaluation decreased from 91.7 to 25.1 % (decrease 72.6 %, p < 0.0001). The negative appendectomy rate was similar; 5.4 % prior, 4.9 % post (p = 0.955). The missed appendicitis rate did not statistically change; 1.1 % prior, 3.7 % post (p = 0.523). The perforation rate was not statistically altered; 6.5 % prior; 9.8 % post (p = 0.421). 350 less patients underwent CT during the year following the pathway.

Conclusions

The staged imaging pathway resulted in a marked decrease in children exposed to CT without compromising diagnostic accuracy.

     

Prevalence of nonalcoholic fatty liver disease in normal-weight and overweight preadolescent children in Haryana,India

Objective

To document the prevalence of non-alcoholic fatty liver disease (NAFLD) and metabolic parameters among normalweight and overweight schoolchildren.

Design

Cross-sectional study.

Setting

Thirteen private schools in urban Faridabad, Haryana.

Participants

961 school children aged 5-10 years.

Methods

Ultrasound testing was done, and 215 with fatty liver on ultrasound underwent further clinical, biochemical and virological testing.

Outcome measures

Prevalence of fatty liver on ultrasound, and NAFLD and its association with biochemical abnormalities and demographic risk factors.

Results

On ultrasound, 215 (22.4%) children had fatty liver; 18.9% in normal-weight and 45.6% in overweight category. Presence and severity of fatty liver disease increased with body mass index (BMI) and age. Among the children with NAFLD, elevated SGOT and SGPT was observed in 21.5% and 10.4% children, respectively. Liver enzyme derangement was significantly higher in overweight children (27% vs 19.4% in normal-weight) and severity of fatty liver (28% vs 20% in mild fatty liver cases). Eleven (8.1%) children with NAFLD had metabolic syndrome. Higher BMI (OR 35.9), severe fatty liver disease (OR 1.7) and female sex (OR 1.9) had strong association with metabolic syndrome.

Conclusions

22.4% of normal-weight and overweight children aged 5-10 years had fatty liver. A high proportion (18.9%) of normal-weight children with fatty liver on ultrasound indicates the silent burden in the population.