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

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.

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.

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

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.: Do normal leukocyte count and C-reactive protein value exclude acute appendicitis in children?.

 Acta Pediatr  2001; 90:649-651.

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.

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]

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.

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.

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 conversion to an oral regimen.

 Am J Surg  2008; 195:141-143.

Surgical Management 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.

Surgical ManagementSurgical 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.

Surgical ManagementSurgical ManagementPerforated Appendicitis

Causes of failure of nonoperative management1. 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

management of perforated appendicitis in children: Can CT predict outcome?. Pediatr Radiol  2007; 37:251-255.

Surgical ManagementSurgical 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

Surgical ManagementSurgical 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.

Radiological imagingRadiological imaging

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

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.

AppendicitisAppendicitisKey anatomical points

AppendicitisAppendicitisKey anatomical points

Laparoscopic AppendicectomyLaparoscopic Appendicectomy

Laparoscopic AppendicectomyLaparoscopic Appendicectomy

Laparoscopic AppendicectomyLaparoscopic Appendicectomy

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.

Open AppendicectomyOpen Appendicectomy Transverse incision Protect wound Swab out pelvis Muscle cutting laparotomy in presence of

peritonitis