Introduction. For acute appendicitis - the most frequent condition to perform an urgent abdominal operation in pediatric surgery - surgical appendectomy still remains the gold standard regarding treatment, nevertheless nonsurgical management has become more and more recognized as a treatment method for uncomplicated acute appendicitis (UAA). However there are still many unanswered questions regarding possible factors that could predict the treatment outcome as well as appropriate antimicrobial drug regimens.
Aim of the Study. The aim was to investigate if there is a possible association between factors such as C-reactive protein (CRP) level, presence of appendicolith, the diameter of the appendix and treatment outcome; as well as to identify most successfully used antimicrobial drug combinations.
Material and methods. A retrospective analysis of hospital cases, admitted to a single reference center during the time period from 2013 to 2015. Patients with clinical signs of acute appendicitis, elevated inflammatory markers and radiological findings suggestive for acute appendicitis were included in the study. Nonsurgical treated patients were divided in two groups based on the treatment outcome - successful or unsuccessful. Analysis of the three factors (CRP level, presence of appendicolith and the diameter of the appendix) and most commonly used antimicrobial drug regimen association with treatment outcome was performed.
Results. Overall 384 children medical records with acute appendicitis were registered and non-surgical treatment was initiated in 147/384 (38 %) cases. Successful treatment outcome of nonsurgical management was identified in 114/147 (78 %) cases. Analyzing prognostic adverse factors results presents no statistically significant difference in association with CRP level >25 mg/l (p=0,479), presence of appendicolith (p=0,183) and the diameter of appendix >1 cm (p=0,183) with successful or unsuccessful treatment outcome. The two most commonly used antimicrobial drug combinations were - Ampicillin/Metronidazole for 49 patients and Ampicillin/Gentamicin for 44 patients. No relevance with treatment outcome and used antimicrobial agents was detected (p=0,597).
The overall recurrence rate after initial presentation is 15 % (17/114). In 3 cases (3 %) recurrent appendicitis developed one month after discharge and in 14 cases (12 %) up to one year after discharge.
Conclusions. Prognostic adverse factors - CRP, presence of appendicolith and diameter of appendix - were not statistically reliable in association with initial non-surgical treatment outcome. The success rate of conservative treatment with narrow spectrum antibiotics was 78 %, which is just as high as in cases treated conservatively with broad-spectrum antibiotics from previous studies. Therefore the question of which factors and antimicrobial drug combinations influence the course of treatment still remains unanswered and further studies are required.
1. Addis DG, Shaffer N, Fowler BS, et al. The epidemiology of appendicitis and appendectomy in the United States. //Am J Epidemiol 1990;132:910–25. Jeff Armstrong, Neil Merritt, Sarah Jones, Leslie Scott, Andreana Bütter. Non-operative management of early, acute appendicitis in children: Is it safe and effective? // J PedSurg 49 (2014) 782–785
3. Peter C. Minneci, Jason P. Sulkowski, Kristine M. Nacion, Justin B. Mahida, Jennifer N. Cooper, R. Lawrence Moss, Katherine J. Deans. Feasibility of a Nonoperative Management Strategy for Uncomplicated Acute Appendicitis in Children // J Am Coll Surg. 2014:219(2):272–279
5. Y. Koike, K. Uchida, K. Matsushita, K. Otake, M. Nakazawa, M. Inoue, M. Kusunoki, Y. Tsukamoto Intraluminal appendiceal fluid is a predictive factor for recurrent appendicitis after initial successful non-operative management of uncomplicated appendicitis in pediatric patients // Journal of Pediatric Surgery 49 (2014) 1116–1121
6. F. Svensson, N. J. Hall S. Eaton, A. Pierro, T. Wester. A Review of Conservative Treatment of Acute Appendicitis // Eur J Pediatr Surg 2012;22:185–194
7. Morgan E. Telesmanich, Robert C. Orth, Wei Zhang et al. Searching for certainty: findings predictive of appendicitis in equivocal ultrasound exams // Pediatr Radiol. 2016 Oct;46(11):1539-45
8. Liang TJ, Liu SI, Tsai CY et al. Analysis of Recurrence Management in Patients Who Underwent Nonsurgical Treatment for Acute Appendicitis // Medicine (Baltimore). 2016;95(12):e3159
9. Vons C, Barry C, Maitre S, et al: Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: An open-label, non-inferiority, randomised controlled trial. Lancet 2011;377:1573-9
10. Liu K, Fogg L: Use of antibiotics alone for treatment of uncomplicated acute appendicitis: A systematic review and meta-analysis. Surgery 2011;150: 673-83
11. Liu K, Ahanchi S, Pisaneschi M, et al: Can acute appendicitis be treated by antibiotics alone? Am Surg 2007;73:1161-5
12. Mason RJ, Moazzez A, Sohn H, et al: Meta-analysis of randomized trials comparing antibiotic therapy with appendectomy for acute uncomplicated (no abscess or phlegmon) appendicitis. Surg Infect 2012;13:74-84
13. Varadhan KK, Neal KR, Lobo DN: Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: Meta-analysis of randomised controlled trials. BMJ 2012;344:e2156
14. Zampieri N, Corroppolo M, El Dalati G et al. Correlation between high-resolution ultrasound and surgical/pathological findings in patients with suspected appendicitis // Minerva Chir. 2008;63(6):469-74
15. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Surg Infect (Larchmt). 2010;11(1):79-109
16. Tanaka Y, Uchida H, Kawashima H et al. Longterm outcomes of operative versus nonoperative treatment for uncomplicated appendicitis. // J Pediatr Surg. 2015;50(11):1893-7