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

Abstract

PurposeA 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.MethodsA 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.ResultsA 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.ConclusionThe 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.

Disease burden of appendectomy for appendicitis: a population-based cohort study

“…The finding in this cohort that incidence peaks among persons aged 10-19 years, and is greater among men compared to women, is consistent with previous epidemiological literature [1,32,36,37]. In 2010, a new Dutch guideline on treatment of appendicitis was published, which incorporates ultrasound or CT imaging in the standard diagnostic process [38,39]. It is plausible that fewer patients were operated as a result due to better diagnosis and a fall in the proportion of appendectomy for appendix sana.…”

“…It is plausible that fewer patients were operated as a result due to better diagnosis and a fall in the proportion of appendectomy for appendix sana. A large Dutch cohort study (n = 1943) performed in 2014 demonstrated a low negative appendectomy rate of 3% [38,39]. Another factor that might play a role is the growing popularity of non-operative treatment and fading dogma 'when in doubt, take it out'.…”

Outcomes after appendectomy in children with acute appendicitis treated at a tertiary paediatric centre: results from a retrospective cohort study

“…The incidence of these two types varies significantly across ages. In the paediatric population, simple appendicitis accounts for the majority of cases, approximately in 65% [3,4]. For over one hundred years, the appendectomy has been the standard of care for all types of acute appendicitis; however, time has not stood still.…”

European Paediatric Surgeons' Association Survey on the Management of Pediatric Appendicitis

“…Recently, a national audit on the outcome of appendectomy for appendicitis in children showed that preoperative imaging, mainly in the form of ultrasonography, is key to reduce the negative appendectomy rate. 11 This may well be the reason why the majority of respondents rely on this non-invasive form of imaging. Likewise, surgeons seem to be aware of the potential risk of ionizing radiations associated with CT scans, 26 and only rarely rely on this imaging technique.…”

“…Following the implementation of these guidelines, two studies have reported a decline in negative appendectomies without an increase in perforation rate. 10,11 Yet, the routine use of imaging to diagnose appendicitis is not unanimously accepted. 12,13 In the last few years, in an effort to evaluate controversial aspects of the management of neonatal and pediatric surgical conditions, the European Paediatric Surgeons' Association (EUPSA) Network Office has administered and analyzed several surveys on the practice patterns of the association members.…”