Is interval appendicectomy justified after successful nonoperative treatment

Is interval appendicectomy justified after successful nonoperative treatment of an appendix mass in children? A systematic review [1] Clerk B 9602054 陳怡如 Clerk B 9602006 江柏興 Clerk B 9505009 李元超

Background � Acute appendicitis enclosed by the omentum and adjacent loops of bowel an appendix mass (AM) � 9% of all children with acute appendicitis have an inflammatory mass (a recent meta-analysis) � Immediate appendectomy may be technically complicated. A high incidence of complications has been reported after that.

Background � Intravenous antibiotics and intestinal rest 8 -12 wks after successful nonoperative treatment, interval appendectomy (IA) � However, this practice has been questioned. The risk of recurrence may be low and there is a morbidity associated with IA.

Purpose � To evaluate the evidence for IA in children after successful nonoperative treatment of an AM

Methods of a Medline search: appendix mass, interval appendectomy, and children � January 1964 to July 2009, reports of successful nonoperative treatment of AM in children (<16 years) � Journal of Pediatric Surgery, Pediatric Surgery International, European Journal of Pediatric Surgery � Keywords

Methods � Inclusion criteria: nonoperative expectant management after successful nonoperative treatment of an AM in children, outcome after IA in children � Data: risk of recurrence, morbidity of IA, unexpected histopathologic findings after IA, and cost

Statistical Analysis � For each outcome measure binomial multilevel modeling technique, “one-sided” meta-analysis � Data relating to length of stay after IA were reported in an inconsistent fashion among individual studies descriptive form only

Recurrent acute appendicitis • 3 studies, total 127 children without IA • Recurrent range: 0%~42% • Overall incidence : 20. 5% (95% CI, 14. 3~28. 4)

Recurrent acute appendicitis • Time to recurrence of acute appendicitis was reported by both studies • One study reported : presence of faecolith, incidence

Morbidity of IA • Complications: wound infection, prolonged post-op ileus hematoma and intestinal obstruction • 23 studies (1247 children ) incidence complication: 3. 4%

Histologic findings • 15 studies (955 patients) findings: normal appendix with no inflammation, residual acute inflammation chronic inflammation • Incidence of carcinoid tumor in specimens removed at IA : 0. 9%

Discussion � Retrospective review studies limit the strength of the ◦ Unable to identify any data comparing IA & nonoperative management ◦ Inform current practice of obtaining prospective data

Discussion � Pros and cons of IA and “watchful waiting” Pros Cons IA Remove the risk of recurrence Risk of complication (3. 4%) Hospital cost (~3 day) Watchful waiting Avoid IA Risk of recurrence (20. 5%) Emergency operation Undetected carcinoid tumor (<1%)

Additional Researches � Frequency of morbidity a/w IA versus risk of recurrence in patients w/o IA [2] ◦ not substantially different (11% versus 7%) ◦ (morbidity: eg, postoperative infection, intestinal fistula, small bowel obstruction) ◦ Nonoperative treatment �Most recurrences developed within 6 months of hospital discharge. � 20% required percutaneous abscess drainage � 2 % delayed the diagnosis of Crohn's disease and cancer, more common in adult patients

Additional Researches � The rate of recurrence in children with an appendicolith was significantly higher than in those without an appendicolith (76% versus 26%) [3]

Additional Researches � For perforated appendicitis with a wellformed abscess ◦ NO difference in total length of hospitalization, recurrent abscess rates, or overall charges between initial LA & IA [4] ◦ Interval appendectomy is controversial

Additional Researches � Advanced appendicitis (perforation/ gangrene) without an appendiceal mass or phlegmon should usually be treated with early appendectomy [5] ◦ time to return to normal activities (mean number of days: 14 versus 19) ◦ reduced adverse events (eg, abscess, small bowel obstruction, or unplanned readmission) (30% versus 55 %) ◦ hospital charges ($17, 450 versus $22, 518)[6]

Additional Researches � The role of routine interval appendectomy is questioned recently. [7] ◦ the risk of recurrence is low (5%-14%) ◦ recurrences usually exhibit a milder clinical course compared to the first episode of AA [8, 9]

References 1. 2. 3. 4. 5. 6. 7. 8. 9. Hall, N. J. , et al. , Is interval appendicectomy justified after successful nonoperative treatment of an appendix mass in children? A systematic review. J Pediatr Surg, 2011. 46(4): p. 767 -71. Andersson, R. E. and M. G. Petzold, Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis. Ann Surg, 2007. 246(5): p. 741 -8. Ein, S. H. , J. C. Langer, and A. Daneman, Nonoperative management of pediatric ruptured appendix with inflammatory mass or abscess: presence of an appendicolith predicts recurrent appendicitis. J Pediatr Surg, 2005. 40(10): p. 1612 -5. St Peter, S. D. , et al. , Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. J Pediatr Surg, 2010. 45(1): p. 236 -40. Blakely, M. L. , et al. , Early vs interval appendectomy for children with perforated appendicitis. Arch Surg, 2011. 146(6): p. 660 -5. Myers, A. L. , et al. , Hospital cost analysis of a prospective, randomized trial of early vs interval appendectomy for perforated appendicitis in children. J Am Coll Surg, 2012. 214(4): p. 42734; discussion 434 -5. Sakorafas, G. H. , et al. , Interval routine appendectomy following conservative treatment of acute appendicitis: Is it really needed. World J Gastrointest Surg, 2012. 4(4): p. 83 -6. Dixon, M. R. , et al. , An assessment of the severity of recurrent appendicitis. Am J Surg, 2003. 186(6): p. 718 -22; discussion 722. Kaminski, A. , et al. , Routine interval appendectomy is not justified after initial nonoperative treatment of acute appendicitis. Arch Surg, 2005. 140(9): p. 897 -901.