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Woo and Choi: In Pediatric Patients with Presumed Appendicitis, Is the Urgent Appendectomy the Best? - Appropriate Management for Pediatric Patients with Presumed Acute Appendicitis -
Original Article
Journal of the Korean Surgical Society

Journal of the Korean Surgical Society 2011; 80(3): 226-233.

Published online: 16 March 2011

DOI: https://doi.org/10.4174/jkss.2011.80.3.226

In Pediatric Patients with Presumed Appendicitis, Is the Urgent Appendectomy the Best? - Appropriate Management for Pediatric Patients with Presumed Acute Appendicitis -

Ju-Hyun Woo, M.D., Kum-Ja Choi, M.D.

Department of Surgery, Ewha Womans University School of Medicine, Seoul, Korea.

Corresponding author (kumchoi@ewha.ac.kr)

Received 2 September 2010       Accepted 8 February 2011

Copyright © 2011 The Korean Surgical Society

Abstract

Purpose

The emerging studies have suggested steadily negative appendectomy rates. The purpose of this study is to verify that short-term observation under conservative management helps surgeons avoid unnecessary surgery without poor progress in pediatric patients with presumed acute appendicitis.

Methods

We reviewed 650 medical records of pediatric patients aged 12 years and younger with presumed acute appendicitis at Ewha Womans University Medical Center between January 2005 and December 2009. We then compared 283 'appendectomy group (AG)' including 229 suppurative appendicitis (SA) and 54 normal appendix or mild appendicitis (MA), pathologically, with 96 'conservative treatment group (CG)' who were diagnosed with mesenteric lymphadenopathy associated with early appendicitis or normal appendix in radiologic study and effectively treated with conservative management.

Results

There was no significant difference in gender and age distribution between SA and MA groups, but the mean age of CG was younger than MA group (P=0.000). The main clinical findings between SA, MA and CG were similar but the mean duration of symptom was longest in CG. 'Delayed' and 'night-time' surgery was frequent in MA (P=0.006, P=0.027). Thirteen patients(4.6%) developed complications in AG without significant difference between SA and MA. The mean hospital stay was significantly shorter in CG than MA (P=0.000) without significant difference between SA and MA. The medical cost of CG was much cheaper than AG (P=0.000). No patient in CG needed appendectomy for the follow-up period.

Conclusion

The authors suggested that short-term watchful waiting for presumed appendicitis in pediatric patients under conservative treatment could reduce unnecessary appendectomy, complications and cost.

Keywords: Presumed appendicitis, Children, Appropriate management

Figures and Tables

Fig. 1
Diagram of study materials.
jkss-80-226-g001
Table 1
Gender and age distribution of simple appendicitis and conservative treatment groups
jkss-80-226-i001

*At Chi-square test (Chi-square test for trend); †At student T-test.

Table 2
Clinical characteristics of simple appendicitis and conservative treatment groups
jkss-80-226-i002

*At Chi-square test; †At student T-test; ‡Fever = body temperature at admission ≥38℃; §Leukocytosis = WBC count at admission ≥15,000/mm3.

Table 3
Comparison of surgical factors in simple appendicitis and conservative treatment groups
jkss-80-226-i003

*At Chi-square test (Chi-square test for trend); †At student T-test; ‡Urgent = administration of preoperative antibiotics = 1 time; §Delayed = administration of preoperative antibiotics ≥2 times.

Table 4
Comparison of hospital stay, complications and medical cost in simple appendicitis and conservative treatment groups
jkss-80-226-i004

*At Chi-square test (Chi-square test for trend); †At student T-test.

Table 5
Comparison of hospital stay, complications and medical costs in appendectomy without observation, appendectomy after observation, and conservative treatment groups
jkss-80-226-i005

*At Chi-square test (Chi-square test for trend); †At student T-test; ‡Wound problem in 5 cases, intraperitoneal abscess in 2 cases and ileus in 2 cases; §Wound problem in all cases.

References

1. International Pediatric Endoscopy Group (IPEG). IPEG guidelines for appendectomy. J Laparoendosc Adv Surg Tech A. 2009. 19:Suppl 1. vii–ix.
2. Morrow SE, Newman KD. Current management of appendicitis. Semin Pediatr Surg. 2007. 16:34–40.
3. Vissers RJ, Lennarz WB. Pitfalls in appendicitis. Emerg Med Clin North Am. 2010. 28:103–118.
4. Simillis C, Symeonides P, Shorthouse AJ, Tekkis PP. A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess of phlegmon). Surgery. 2010. 147:818–829.
5. Wong KK, Cheung TW, Tam PK. Diagnosing acute appendicitis: are we overusing radiologic investigations? J Pediatr Surg. 2008. 43:2239–2241.
6. Velanovich V, Satava R. Balancing the normal appendectomy rate with the perforated appendicitis rate: Implications for quality assurance. Am Surg. 1992. 58:264–269.
7. Perez J, Barone JE, Wilbanks TO, Jorgensson D, Corvo PR. Liberal use of computed tomography scanning does not improve diagnostic accuracy in appendicitis. Am J Surg. 2003. 185:194–197.
8. Bae H, Noh H, Jang HY, Jung KY. Medicolegal consideration of acute appendicitis: Based on judicial precedents. J Korean Surg Soc. 2007. 72:223–229.
9. Neufeld D, Vainrib M, Buklan G, Gutermacher M, Paran H, Werner M, et al. Management of acute appendicitis: a imaging strategy in children. Pediatr Surg Int. 2010. 26:167–171.
10. Cho SH, Jeong M, Lee TH. Results of observation versus operation for right lower abdominal pain in pediatric patients. J Korean Surg Soc. 1992. 42:245–254.
11. Sasso RD, Hanna EA, Moore DL. Leukocytic and neutrophilic counts in acute appendicitis. Am J Surg. 1970. 120:563–566.
12. Doraiswamy NV. Leukocyte counts in the diagnosis and prognosis of the acute appendicitis in children. Br J Surg. 1979. 66:782–784.
13. Newman K, Ponsky T, Kittle K, Dyk L, Throop C, Gieseker K, et al. Appendicitis 2000: variability in practice, outcomes, and resource utilization at thirty pediatric hospitals. J Pediatr Surg. 2003. 38:372–379.
14. Applegate KE, Sivit CJ, Salvator AE, Borisa VJ, Dudgeon DL, Stallion AE, et al. Effect of cross-sectional imaging on negative appendectomy and perforation rates in children. Radiology. 2001. 220:103–107.
15. Kosloske AM, Love CL, Rohrer JE, Goldthorn JF, Lacey SR. The diagnosis of appendicitis in children: outomes of a strategy based on pediatric surgical evaluation. Pediatrics. 2004. 113:29–34.
16. Partrick DA, Janik JE, Janik JS, Bensard DD, Karrer FM. Increased CT scan utilization does not improve the diagnostic accuracy of appendicitis in children. J Pediatr Surg. 2003. 38:659–662.
17. Rao PM, Rhea JT, Rattner DW, Venus LG, Novelline RA. Introduction of appendiceal CT: impact on negative appendectomy and appediceal perforation rates. Ann Surg. 1999. 229:344–349.
18. Douglas CD, Macpherson NE, Davidson PM, Gani JS. Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score. BMJ. 2000. 321:919–922.
19. Price RO, Jeffrey RB, Vasanawala SS. Appendiceal hyperemia and/or distention is not always appendicitis: appendicitis mimicry in the pediatric population. Clin Imaging. 2009. 33:402–405.
20. Flum DR, McClure TD, Morris A, Koepsell T. Misdiagnosis of appendicitis and the use of diagnostic imaging. J Am Coll Surg. 2005. 201:933–939.
21. Lee SK, Kim DY, Kim SY, Kim SC, Kim SG, Kim WK, et al. Acute appendicitis: a survey by the Korean Association of Pediatric Surgeons in 2006. J Korean Assoc Pediatr Surg. 2007. 13:203–211.
22. Macklin CP, Radcliffe GS, Merei JM, Stringer MD. A prospective evaluation of the modified Alvarado score for acute appendicitis in children. Ann R Coll Surg Engl. 1997. 79:203–205.
23. Samuel M. Pediatric appendicitis score. J Pediatr Surg. 2002. 37:877–881.
24. Strouse PJ. Pediatric appendicitis: an argument for US. Radiology. 2010. 255:8–13.
25. Flum DR, Koepsell T. The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg. 2002. 137:799–804.
26. Bijnen CL, van den Broek WT, Bijenen AB, de Ruiter P, Gouma DJ. Implications of removing a normal appendix. Dig Surg. 2003. 20:115–121.
27. McGory ML, Zingmond DS, Tillou A, Hiatt JR, Ko CY, Cryer HM. Negative appendectomy in pregnant women is associated with substantial risk of fetal loss. J Am Coll Surg. 2007. 205:534–540.
28. Gough IR, Morris MI, Pertnikovs EI, Murry MR, Smith MB, Bestmann MS. Consquences of removal of a normal appendix. Med J Aust. 1983. 1:370–372.
29. Ponsky TA, Hafi M, Heiss K, Dinsmore J, Newman KD, Gilbert J. Interobserver variation in the assessment of appendiceal perforation. J Laparoendosc Adv Surg Tech A. 2009. 19:S15–S18.
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