On the treatment of acute appendicitis in children

Abstract

Acute appendicitis is a common condition in children and the treatment of this condition is both straightforward and complex at the same time. An appendectomy is the most common acute surgical intervention in children and the vast majority of children make a swift recovery without any complications. The surgical modality is however shifting from open to minimal access surgery and now further onto non-operative treatment. A well-performed clinical examination is still imperative but is currently aided by both evolving scoring systems and imaging. Imaging is developing from ultrasound via computed tomography-scanning to magnetic resonance imaging. The traditional belief that an inflamed appendix always progresses to gangrene and perforation does not hold its ground. Spontaneous resolution of acute appendicitis appears to be common.

The aim of this thesis was to present modern benchmarks of different treatment modalities of acute appendicitis today, to present current evidence of non-operative treatment of acute appendicitis and to test if non-operative treatment of acute appendicitis in children is safe and feasible. All clinical studies have been based on children treated at the Astrid Lindgren Children´s Hospital, Stockholm, Sweden.

In paper I we conducted a review of all children who underwent an appendectomy for acute appendicitis between 2006 and 2010. 1744 patients were operated, 1009 had a laparoscopic operation. We found no difference in the rate of complications between the two methods. We found that the operating time was longer for laparoscopic surgery and that the initial assumption that the postoperative length of stay in the laparoscopic group was shorter than in the open group was not due to the surgical modality but to a general trend over time.

In paper II we studied recurrence of acute appendicitis in children after successful non-operative treatment of an imaging-confirmed appendiceal abscess. 89 patients were included in this study. Nine patients had an appendectomy during the 5.1 years of follow-up but only 2 had a recurrent acute appendicitis. Hence, the recurrence rate was 2.4% during 5.1 years of follow-up. This finding supports the strategy of not performing interval appendectomies on a routine basis.

In paper III we performed a meta-analysis on randomised controlled trials on non-operative treatment of acute appendicitis in adults. We included 4 trials with a total of 896 patients. There were no difference in treatment failure but there were fewer complications in the non-operative treatment group. 73% of patients were found not to have had an appendectomy during 1 year of follow-up. We concluded that a randomised controlled trial in children was warranted.

In paper IV we conducted a randomised controlled pilot trial of non-operative treatment versus surgery of acute appendicitis in children. We enrolled 50 patients in the trial, 26 were randomised to surgery. In the surgery group, all patients had a histologically confirmed acute appendicitis; none of these patients had any significant complications. Of the patients treated non-operatively with antibiotics, 92% had initial resolution of symptoms and only one patient (5%) had recurrence of acute appendicitis during the one-year follow-up period. Overall, 62% of patients have not had an appendectomy during the follow-up.