Follow-up study On timing, clinical manifestations, predictors of re-inflammation of the appendix, and choice of treatment tactics in children

Abstract

BACKGROUND: Reports of successful conservative treatment of acute appendicitis in children demonstrate the effectiveness of primary treatment in 89%–97% of cases. Data for evaluating outcomes with a follow-up period of more than 5 years are available.

AIM: This study aimed to develop techniques for the follow-up observation of children after regression of inflammation in the appendix and for re-inflammation by establishing the prevailing timing and possible predictors of relapse.

MATERIALS AND METHODS: The study was based on the results of a follow-up observation of 92 patients who had previously received medical care until October 2023 because of an episode of inflammation in the appendix with regression. The disease was diagnosed using the pediatric appendicitis score and ultrasound. Thirteen children underwent appendectomy without therapy. Conservative treatment was performed in eight patients, which was ineffective in four (50%) of them, who also required appendectomy.

RESULTS: The patients were divided into two main groups: with relapse of inflammation in the appendix (20 patients, 21.7%) and without relapse (72 children, 78.2%). The relapse rate was 21.7% (20 of 92 children), cumulative disease-free survival was 49.3 ± 8.6%, and surgical-free survival was 54.3 ± 8.7%. A comparative analysis of clinical, laboratory, and ultrasonographic data obtained during the first episode of inflammation did not reveal reliable predictors of relapse (p > 0.28). The duration of observation in patients without relapse ranged from 1 to 74 months (median: 36 [LQ 25; UQ 54] months). In 25 (34.7%) of them, the observation was interrupted owing to reaching the age of 18 years, over a follow-up period from 1 to 70 months (26 [LQ 15; UQ 38] months).

CONCLUSIONS: Data demonstrate a relatively low occurrence of relapses of inflammation of the appendix after effective conservative treatment. The study did not reveal any significant predictors of an increased risk of relapse. Conservative therapy for recurrent inflammation can be conducted; however, it is less effective than for the primary episode.

Keywords

appendicitis / regression / inflammation / relapse / treatment / children

References

[1] McBurney C. Experiences with early operative interference in cases of disease of the vermiform appendix. New York Medical Journal. 1889;50:1676–1684.

[2] McBurney C. Experiences with early operative interference in cases of disease of the vermiform appendix // New York Medical Journal. 1889. Vol. 50. P. 1676–1684.

[3] Gurin NN, Slobodchuk JuS, Gavrilov JuF. On the effectiveness of conservative treatment of patients with acute appendicitis on ships at sea. Bulletin of Surgery. 1992;5:144–150. (In Russ.)

[4] Гурин, Н.Н., Слободчук Ю.С., Гаврилов Ю.Ф. Об эффективности консервативного лечения больных с острым аппендицитом на судах в море // Вестник хирургии. 1992. № 5. С. 144–150.

[5] Harrison PW. Appendicitis and the antibiotics. Am J Surg. 1953;85(2):160–163. doi: 10.1016/0002-9610(53)90476-0

[6] Harrison P.W. Appendicitis and the antibiotics // Am J Surg. 1953. Vol. 85, N 2. P. 160–163. doi: 10.1016/0002-9610(53)90476-0

[7] Coldrey E. Five years of conservative treatment of acute appendicitis. J Int Col Surg. 1959;32:255–261.

[8] Coldrey E. Five years of conservative treatment of acute appendicitis // J Int Coll Surg. 1959. Vol. 32. P. 255–261.

[9] Wilms IM, de Hoog DE, de Visser DC, Janzing HM. Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev. 2011;11:CD008359. doi: 10.1002/14651858.CD008359.pub2

[10] Wilms I.M., de Hoog D.E., de Visser D.C., Janzing H.M. Appendectomy versus antibiotic treatment for acute appendicitis // Cochrane Database Syst Rev. 2011. N 11. P. CD008359. doi: 10.1002/14651858.CD008359.pub2

[11] Harnoss JC, Zelienka I, Probst P, et al. Antibiotics versus surgical therapy for uncomplicated appendicitis: Systematic review and meta-analysis of controlled trials. Ann Surg. 2017;265(5):889–900. doi: 10.1097/SLA.0000000000002039

[12] Harnoss J.C., Zelienka I., Probst P., et al. Antibiotics versus surgical therapy for uncomplicated appendicitis: Systematic review and meta-analysis of controlled trials // Ann Surg. 2017. Vol. 265, N 5. P. 889–900. doi: 10.1097/SLA.0000000000002039

[13] Salminen P, Tuominen R, Paajanen H, et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA. 2018;320(12):1259–1265. doi: 10.1001/jama.2018.13201

[14] Salminen P., Tuominen R., Paajanen H., et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial // JAMA. 2018. Vol. 320, N 12. P. 1259–1265. doi: 10.1001/jama.2018.13201

[15] All-Russian Public Organization “Russian Society of Surgeons”, Russian Society of Endoscopic Surgeons. Acute appendicitis in adults: clinical recommendations. Moscow: Ministry of Health of the Russian Federation; 2017. 51 p. [cited 2004 July 3]. Available from: https://cr.minzdrav.gov.ru/schema/325_2. (In Russ.)

[16] Общероссийская общественная организация «Российское общество хирургов», Российское общество эндоскопических хирургов. Острый аппендицит у взрослых: клинические рекомендации. Москва: Министерство здравоохранения Российской Федерации, 2017. 51 с. Режим доступа: https://cr.minzdrav.gov.ru/schema/325_2. Дата обращения: 03.07.2024.

[17] Shipsey MR, O’Donnell B. Conservative management of appendix mass in children. Ann R Coll Surg Engl. 1985;67(1):23–24.

[18] Shipsey M.R., O’Donnell B. Conservative management of appendix mass in children // Ann R Coll Surg Engl. 1985. Vol. 67, N 1. P. 23–24.

[19] Gillick J, Velayudham M, Puri P. Conservative management of appendix mass in children. Br J Surg. 2001;88(11):1539–1542. doi: 10.1046/j.0007-1323.2001.01912.x

[20] Gillick J., Velayudham M., Puri P. Conservative management of appendix mass in children // Br J Surg. 2001. Vol. 88, N 11. P. 1539–1542. doi: 10.1046/j.0007-1323.2001.01912.x

[21] Svensson JF, Almstrom M, Naji H, et al. Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: A pilot randomized controlled trial. Ann Surg. 2015;261:67–71. doi: 10.1097/sla.0000000000000835

[22] Svensson J.F., Almstrom M., Naji H., et al. Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: A pilot randomized controlled trial // Ann Surg. 2015 Vol. 261 P. 67–71. doi: 10.1097/sla.0000000000000835

[23] Minneci PC, Mahida JB, Lodwick DL, et al. Effectiveness of patient choice in nonoperative vs surgical management of pediatric uncomplicated acute appendicitis. JAMA Surg. 2016;151(5):408–415. doi: 10.1001/jamasurg.2015.4534

[24] Minneci P.C., Mahida J.B., Lodwick D.L., et al. Effectiveness of patient choice in nonoperative vs surgical management of pediatric uncomplicated acute appendicitis // JAMA Surg. 2016. Vol. 151, N 5. P. 408–415. doi: 10.1001/jamasurg.2015.4534

[25] Georgiou R, Eaton S, Stanton MP, et al. Efficacy and safety of nonoperative treatment for acute appendicitis: a meta-analysis. Pediatrics. 2017;139(3):e20163003. doi: 10.1542/peds.2016-3003

[26] Georgiou R., Eaton S., Stanton M.P., et al. Efficacy and safety of nonoperative treatment for acute appendicitis: a meta-analysis // Pediatrics. 2017. Vol. 139, N 3. P. e20163003. doi: 10.1542/peds.2016-3003

[27] Huang L, Yin Y, Yang L, et al. Comparison of antibiotic therapy and appendectomy for acute uncomplicated appendicitis in children: a meta-analysis. JAMA Pediatr. 2017;171(5):426–434. doi: 10.1001/jamapediatrics.2017.0057

[28] Huang L., Yin Y., Yang L., et al. Comparison of antibiotic therapy and appendectomy for acute uncomplicated appendicitis in children: a meta-analysis // JAMA Pediatr. 2017. Vol. 171, N 5. P. 426–434. doi: 10.1001/jamapediatrics.2017.0057

[29] Diakonova EYu. Comments by E.Yu. Dyakonova to the article “Effectiveness of patient choice in nonoperative vs surgical management of pediatric uncomplicated acute appendicitis”. Current Pediatrics (Moscow). 2016;15(1):111. doi: 10.15690/vsp.v15i1.1508

[30] Дьяконова Е.Ю. Комментарии Е.Ю. Дьяконовой к статье «Эффективность выбора пациентом между консервативным и хирургическим способом лечения неосложненного острого аппендицита у детей» // Вопросы современной педиатрии. 2016. T. 15, № 1. C. 109–111. EDN: VLMFRX doi: 10.15690/vsp.v15i1.1508

[31] Patkova B, Svenningsson A, AlmstrÖm M, et al. Nonoperative treatment versus appendectomy for acute nonperforated appendicitis in children: Five-year follow up of a randomized controlled pilot trial. Ann Surg. 2020;271(6):1030–1035. doi: 10.1097/sla.0000000000003646

[32] Patkova B., Svenningsson A., AlmstrÖm M., et al. Nonoperative treatment versus appendectomy for acute nonperforated appendicitis in children: Five-year follow up of a randomized controlled pilot trial // Ann Surg. 2020. Vol. 271, N 6. P. 1030–1035. doi: 10.1097/sla.0000000000003646

[33] Steiner Z, Gilad Y, Gutermacher M, et al. Acute appendicitis in children: Reexamining indications for conservative treatment — A large prospective analysis. J Pediatr Surg. 2022;57(10):373–379. doi: 10.1016/j.jpedsurg.2021.12.012

[34] Steiner Z., Gilad Y., Gutermacher M., et al. Acute appendicitis in children: Reexamining indications for conservative treatment — A large prospective analysis // J Pediatr Surg. 2022. Vol. 57, N 10. P. 373–379. doi: 10.1016/j.jpedsurg.2021.12.012

[35] Blandinskiy VF, Sokolov SV, Anfinogenov AL, et al. Clinical, laboratory and ultrasonographic criteria for inflammation of the appendix and its regression in children. Russian Journal of Pediatric Surgery. 2023;27(4):254–260. EDN: YLYCPV doi: 10.55308/1560-9510-2023-27-4-254-260

[36] Бландинский В.Ф., Соколов С.В., Анфиногенов А.Л., и др. Клинико-лабораторные и ультрасонографические критерии воспаления в червеобразном отростке слепой кишки и его регрессии у детей // Детская хирургия. 2023. Т. 27, № 4. С. 254–260. EDN: YLYCPV doi: 10.55308/1560-9510-2023-27-4-254-260

[37] Samuel M. Pediatric appendicitis score. J Pediatr Surg. 2002;37(6):877–881. doi: 10.1053/jpsu.2002.32893

[38] Samuel M. Pediatric appendicitis score // J Pediatr Surg. 2002. Vol. 37, N 6. P. 877–881. doi: 10.1053/jpsu.2002.32893

[39] Isakov YF, Stepanov EA, Dronov AF. Acute appendicitis in childhood. Moscow: Meditsina; 1980. 192 p. (In Russ.)

[40] Исаков Ю.Ф., Степанов Э.А. Дронов А.Ф. Острый аппендицит в детском возрасте. Москва: Медицина, 1980. 192 c.

[41] Rich JT, Neely JG, Paniello RC, et al. A practical guide to understanding Kaplan–Meier curves. Otolaryngol Head Neck Surg. 2010;143(3):331–336. doi: 10.1016/j.otohns.2010.05.007

[42] Rich J.T., Neely J.G., Paniello R.C., et al. A practical guide to understanding Kaplan–Meier curves // Otolaryngol Head Neck Surg. 2010. Vol. 143, N 3. P. 331–336. doi: 10.1016/j.otohns.2010.05.007

[43] Bachur RG, Lipsett SC, Monuteaux MC. Outcomes of nonoperative management of uncomplicated appendicitis. Pediatrics. 2017;140(1):e20170048. doi: 10.1542/peds.2017-0048

[44] Bachur R.G., Lipsett S.C., Monuteaux M.C. Outcomes of nonoperative management of uncomplicated appendicitis // Pediatrics. 2017. Vol. 140, N 1. P. e20170048. doi: 10.1542/peds.2017-0048

[45] Eriksson S, Granström L. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. Br J Surg. 1995;82(2):166–169. doi: 10.1002/bjs.1800820207

[46] Eriksson S., Granström L. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis // Br J Surg. 1995. Vol. 82, N 2. P. 166–169. doi: 10.1002/bjs.1800820207

[47] Hartwich J, Luks FI, Watson-Smith D, et al. Nonoperative treatment of acute appendicitis in children: A feasibility study. J Pediatr Surg. 2016;51(1):111–116. doi: 10.1016/j.jpedsurg.2015.10.024

[48] Hartwich J., Luks F.I., Watson-Smith D., et al. Nonoperative treatment of acute appendicitis in children: A feasibility study // J Pediatr Surg. 2016. Vol. 51, N 1. P. 111–116. doi: 10.1016/j.jpedsurg.2015.10.024

[49] Haxhirexha K, Dogjani A, Zylbehari L, Dika-Haxhirexha F. Misdiagnosed appendicitis in children. Albanian Journal of Trauma and Emergency Surgery. 2018;2(2):99–104. doi: 10.32391/ajtes.v2i2.14

[50] Haxhirexha K., Dogjani A., Zylbehari L., Dika-Haxhirexha F. Misdiagnosed appendicitis in children // Albanian Journal of Trauma and Emergency Surgery. 2018. Vol. 2, N. 2. P. 99–104. doi: 10.32391/ajtes.v2i2.14

[51] Galai T, Beloosesky OZ, Scolnik D, et al. Misdiagnosis of acute appendicitis in children attending the emergency department: the experience of a large, tertiary care pediatric hospital. Eur J Pediatr Surg. 2017;27(2):138–141. doi: 10.1055/s-0035-1570757

[52] Galai T., Beloosesky O.Z., Scolnik D., et al. Misdiagnosis of acute appendicitis in children attending the emergency department: the experience of a large, tertiary care pediatric hospital // Eur J Pediatr Surg. 2017. Vol. 27, N 2. P. 138–141. doi: 10.1055/s-0035-1570757

[53] Chang YJ, Chao HC, Kong MS, et al. Misdiagnosed acute appendicitis in children in the emergency department. Chang Gung Med J. 2010;33(5):551–557.

[54] Chang Y.J., Chao H.C., Kong M.S., et al. Misdiagnosed acute appendicitis in children in the emergency department // Chang Gung Med J. 2010. Vol. 33, N 5. P. 551–557.

[55] Sippola S, Haijanen J, Viinikainen L, et al. Quality of life and patient satisfaction at 7-year follow-up of antibiotic therapy vs appendectomy for uncomplicated acute appendicitis: a secondary analysis of a randomized clinical trial. JAMA Surg. 2020;155(4):283–289. doi: 10.1001/jamasurg.2019.6028

[56] Sippola S., Haijanen J., Viinikainen L., et al. Quality of life and patient satisfaction at 7-year follow-up of antibiotic therapy vs appendectomy for uncomplicated acute appendicitis: a secondary analysis of a randomized clinical trial // JAMA Surg. 2020. Vol. 155, N 4. P. 283–289. doi: 10.1001/jamasurg.2019.6028

[57] Whyte C, Tran E, Lopez ME, et al. Outpatient interval appendectomy after perforated appendicitis. J Pediatr Surg. 2008;43(11):1970–1972. doi: 10.1016/j.jpedsurg.2008.04.014

[58] Whyte C., Tran E., Lopez M.E., et al. Outpatient interval appendectomy after perforated appendicitis // J Pediatr Surg. 2008. Vol. 43, N 11. P. 1970–1972. doi: 10.1016/j.jpedsurg.2008.04.014

[59] Fuhrer AE, Sukhotnik I, Ben-Shahar Y, et al. Predictive value of Alvarado score and pediatric appendicitis score in the success of nonoperative management for simple acute appendicitis in children. Eur J Pediatr Surg. 2021;31(1):95–101. doi: 10.1055/s-0040-1718406

[60] Fuhrer A.E., Sukhotnik I., Ben-Shahar Y., et al. Predictive value of Alvarado score and pediatric appendicitis score in the success of nonoperative management for simple acute appendicitis in children // Eur J Pediatr Surg. 2021. Vol. 31, N 1. P. 95–101. doi: 10.1055/s-0040-1718406

[61] Loftus TJ, Brakenridge SC, Croft CA, et al. Successful nonoperative management of uncomplicated appendicitis: predictors and outcomes. J Surg Res. 2018;222:212–218e2. doi: 10.1016/j.jss.2017.10.006

[62] Loftus T.J., Brakenridge S.C., Croft C.A., et al. Successful nonoperative management of uncomplicated appendicitis: predictors and outcomes // J Surg Res. 2018. Vol. 222. P. 212–218e2. doi: 10.1016/j.jss.2017.10.006

[63] Macco S, Vrouenraets BC, de Castro SM. Evaluation of scoring systems in predicting acute appendicitis in children. Surgery. 2016;160(6):1599–1604. doi: 10.1016/j.surg.2016.06.023

[64] Macco S., Vrouenraets B.C., de Castro S.M. Evaluation of scoring systems in predicting acute appendicitis in children // Surgery. 2016. Vol. 160, N. 6. P. 1599–1604. doi: 10.1016/j.surg.2016.06.023

[65] Morrow SE, Newman KD. Current management of appendicitis. Semin Pediatr Surg. 2007;16(1):34–40. doi: 10.1053/j.sempedsurg.2006.10.005

[66] Morrow S.E., Newman K.D. Current management of appendicitis // Semin Pediatr Surg. 2007. Vol. 16, N. 1. P. 34–40. doi: 10.1053/j.sempedsurg.2006.10.005

[67] Decker E, Ndzi A, Kenny S, Harwood R. Systematic review and meta-analysis to compare the short- and long-term outcomes of non-operative management with early operative management of simple appendicitis in children after the covid-19 pandemic. J Pediatr Surg. 2023;59(6):1050–1057. doi: 10.1016/j.jpedsurg.2023.12.021

[68] Decker E., Ndzi A., Kenny S., Harwood R. Systematic review and meta-analysis to compare the short- and long-term outcomes of non-operative management with early operative management of simple appendicitis in children after the COVID-19 pandemic // J Pediatr Surg. 2023. Vol. 59, N 6. P. 1050–1057. doi: 10.1016/j.jpedsurg.2023.12.021

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