Appendectomy Versus Observation for Appendicitis in Neutropenic Children With Cancer

Many, Benjamin T.; Lautz, Timothy B.; Dobrozsi, Sarah; Wilkinson, Katheryn Hope; Rossoff, Jenna; Le‐Nguyen, Annie; Dakhallah, Nawar; Piché, Nelson; Weinschenk, Whitney; Cooke-Barker, Jo; Goodhue, Catherine; Zamora, Abigail K.; Kim, Eugene; Talbot, Lindsay J.; Quevedo, Oswaldo Gomez; Murphy, Andrew J.; Commander, Sarah Jane; Tracy, Elisabeth T.; Short, Scott S.; Meyers, Rebecka L.; Rinehardt, Hannah; Aldrink, Jennifer H.; Heaton, Todd E.; Ortiz, Michael V.; Baertschiger, Reto M.; Wong, Kaitlyn E.; Lapidus-Krol, Eveline; Bütter, Andreana; Davidson, Jacob; Stark, Rebecca; Ramaraj, Akila B.; Malek, Marcus M.; Mastropolo, Rosemarie; Morgan, Katrina M.; Murphy, Joseph; Janek, Kevin C.; Le, Hau D.; Dasgupta, Roshni; Lal, Dave R.

doi:10.1542/peds.2020-027797

Cited by 14 publications

(18 citation statements)

References 25 publications

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“…Only 23% of the children could be treated conservatively. Similar results were obtained in a retrospective multicenter study from the USA involving 66 children undergoing cancer treatment, published in Pediatrics 2021 [8]. Of the 66 children, 41% underwent surgery for appendicitis in neutropenia, and 56% were treated conservatively with antibiotics and ± G-CSF.…”

Section: Discussionsupporting

confidence: 74%

“…We recommend surgical therapy in immunosuppressed patients, based on this case report and review of literature, because in all studies discussed here [7][8][9][10], the failure rate of conservative therapy was high and surgery was finally required. The conservative therapy with antibiotics followed by surgical therapy due to therapy failure prolongs the patient's convalescence time.…”

Section: Discussionmentioning

confidence: 87%

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Surgical approach for appendicitis in neutropenia: a case report and review of the literature

et al. 2022

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Background Acute appendicitis is a common abdominal pathology, particularly in younger patients presenting with abdominal pain. The clinical presentation is typically characterized by right lower quadrant pain (with local peritonitis) accompanied by fever and nausea. In neutropenic patients it is challenging to diagnose acute appendicitis. It is much more challenging because the characteristic symptoms are different, and diagnosis may be delayed or missed. Case presentation We present the case of a 33-year-old Caucasian male patient with fever, abdominal pain, and an absolute granulocyte count of 0 × 109/L. Abdominal CT demonstrated an uncomplicated acute appendicitis. We initiated a conservative in-hospital treatment with intravenous antibiotic therapy and simultaneous bone marrow stimulation, with close monitoring. On day three, there was evidence of monocyte increase, one of the first signs of bone marrow regeneration, and delayed laparoscopic appendectomy was performed. The perioperative and postoperative course was uneventful. Conclusion We discuss the different treatment strategies in patients with neutropenia presenting with acute appendicitis (i.e., conservative management, delayed appendectomy, and immediate appendectomy) based on our experience and a review of the literature. In summary, delayed laparoscopic appendectomy at the onset of granulocyte regeneration under antibiotic and G-CSF therapy represents a viable surgical option for adults as well as for children and should be discussed compared with conservative therapy.

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Section: Discussionsupporting

confidence: 74%

Section: Discussionmentioning

confidence: 87%

Surgical approach for appendicitis in neutropenia: a case report and review of the literature

et al. 2022

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“…A recent American study of 66 children with malignancies and neutropenic appendicitis found that upfront surgery (appendectomy within 24 h) was associated with shorter hospital stay, fewer complications, and fewer alterations in chemotherapy regimens compared with the patients treated conservatively. 43 We do not have the power to confirm the benefit of early appendectomy. All patients with appendicitis were between 8 to 16 years of age and only 1 were female.…”

Section: Discussionmentioning

confidence: 96%

Abdominal Complications During Treatment for Pediatric Acute Myeloid Leukemia

Borgstedt-Bendixen

Abrahamsson²,

et al. 2021

Journal of Pediatric Hematology/Oncology

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Acute myeloid leukemia (AML) accounts for 15% to 20% of childhood leukemias. Because of high-intensive therapy, up to 5% of patients suffer from treatment-related mortality (TRM). Abdominal complications are frequent, however, literature on this subject is sparse. We aimed to characterize severe abdominal pain (AP) and hyperbilirubinemia experienced by pediatric AML patients treated according to the Nordic Society of Pediatric Hematology and Oncology (NOPHO)-AML 2004 protocol (n=313). Patients were censored at hematopoietic stem cell transplantation and relapse. Toxicity information was collected prospectively. Additional information was requested retrospectively from the treating centers. Sixteen episodes of hyperbilirubinemia and 107 episodes of AP were reported. The treating centers deemed infection (30%) and typhlitis (18%) as the most frequent causes of AP. Six patients developed appendicitis (2%). Patients experiencing concurrent AP and sepsis had a high risk of TRM (36%, n=4). Eighty percent of episodes with hyperbilirubinemia fulfilled the European Society for Bone and Marrow Transplantation criteria for sinusoidal obstruction syndrome. In conclusion, abdominal complications were frequent with infection considered the predominate cause. Most patients with hyperbilirubinemia fulfilled the criteria for sinusoidal obstruction syndrome. AML treatment might be associated with appendicitis. Patients suffering from concurrent AP and sepsis had a high risk of TRM indicating that high awareness of abdominal complications is essential to reduce mortality, especially during sepsis.

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“…Typhlitis in leukemias often leads to a complicated course requiring gut rest, prolonged antibiotic therapy. Since appendicitis is a close differential diagnosis, there is a considerable dilemma for the surgeon whether to perform a laparotomy in a state of neutropenia[ 39 ]. Pancreatitis during chemotherapy may have an underlying genetic predisposition and may need exploration before induction.…”

Section: Leukemias In Childrenmentioning

confidence: 99%

Gut and liver involvement in pediatric hematolymphoid malignancies

Devarapalli¹,

Sarma²,

Mathiyazhagan³

2022

WJGO

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Hematolymphoid malignancies are common neoplasms in childhood. The involvement of the gastrointestinal (GI) tract, liver, biliary system, pancreas, and peritoneum are closely interlinked and commonly encountered. In leukemias, lymphomas, and Langerhans cell histiocytosis (LCH), the manifestations result from infiltration, compression, overwhelmed immune system, and chemotherapy-induced drug toxicities. In acute leukemias, major manifestations are infiltrative hepatitis, drug induced gastritis, neutropenic typhlitis and chemotherapy related pancreatitis. Chronic leukemias are rare. Additional presentation in lymphomas is cholestasis due to infiltration or biliary obstruction by lymph nodal masses. Presence of ascites needs a thorough workup for the underlying pathophysiology that may modify the therapy and affect the outcome. Uncommon hematolymphoid malignancies are primary hepatic, hepatosplenic, and GI lymphomas which have strict definitions. In advanced diseases with extensive spread, it may be impossible to distinguish these diseases from the primary site of origin. LCH produces biliary strictures that mimic as sclerosing cholangitis. Liver infiltration is associated with poor liver recovery even after chemotherapy. The heterogeneity of gut and liver manifestations in hematolymphoid malignancies has a clinical impact on their management. Though chemotherapy is the mainstay of therapy in all hematolymphoid malignancies, debulking surgery and radiotherapy have an adjuvant role in specific clinical scenarios. Rare situations presenting as liver failure or end-stage liver disease require liver transplantation. At their initial presentation to a primary care physician, given the ambiguity in clinical manifestations and the prognostic difference with time-bound management, it is vital to recognize them early for optimal outcomes. Pooled data from robust registries across the world is required for better understanding of these complications.

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Appendectomy Versus Observation for Appendicitis in Neutropenic Children With Cancer

Cited by 14 publications

References 25 publications

Surgical approach for appendicitis in neutropenia: a case report and review of the literature

Surgical approach for appendicitis in neutropenia: a case report and review of the literature

Abdominal Complications During Treatment for Pediatric Acute Myeloid Leukemia

Gut and liver involvement in pediatric hematolymphoid malignancies

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