Clinical recovery in children with uncomplicated appendicitis undergoing non-operative treatment: secondary analysis of a prospective cohort study

Knaapen, Max; Lee, Johanna H. van der; Heij, Hugo A.; Heurn, Ernst L.W. van; Bakx, Roel; Gorter, Ramon R.

doi:10.1007/s00431-018-3277-9

Cited by 20 publications

(10 citation statements)

References 39 publications

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“…The change to non-operative treatment in eligible patients for certain conditions, for example, appendicitis that is being contemplated, may find less success in Africa, where a higher proportion of patients have complicated disease not amenable to non-operative treatment. 26 It also has the potential to prolong hospital stay, 27 which increases the chances of nosocomial transmission of the virus.…”

Section: Rationing Of Surgical Servicesmentioning

confidence: 99%

Mitigating the impact of COVID-19 on children's surgery in Africa

et al. 2020

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Section: Rationing Of Surgical Servicesmentioning

confidence: 99%

Mitigating the impact of COVID-19 on children's surgery in Africa

et al. 2020

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“…[10][11][12][13][14][15] Of note, conservative treatment leads to symptom relief just after one day and thus is not inferior to appendicectomy concerning this matter. 16 Therefore, the use of ultrasound for the pre-operative differentiation between gangrenous/perforated appendicitis and uncomplicated appendicitis is important, especially in regard of defining treatment groups.…”

Section: Introductionmentioning

confidence: 99%

Sonographic differentiation of complicated from uncomplicated appendicitis

Rawolle

Reismann

Minderjahn

et al. 2019

The British Journal of Radiology

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Objective: This study aims to differentiate acute uncomplicated and complicated appendicitis, by investigating the correlation between sonographic findings and histological results in different types of paediatric appendicitis. Methods: This is a retrospective study of 1017 paediatric patients (age < 18 years) who underwent ultrasound by paediatric radiologists before appendicectomy at our institution between 2006 and 2016. Histologically, uncomplicated appendicitis was primarily associated with transmural infiltration of neutrophil granulocytes, while complicated appendicitis was characterised by transmural myonecrosis. Logistic regression analyses were used to investigate the association between sonographic and histological findings. Results: Out of 566 (56%) male and 451 (44%) female patients with a mean age of 10.7 years, uncomplicated appendicitis was histologically diagnosed in 446 (44%) children and complicated appendicitis was diagnosed in 348 (34%) cases. The following ultrasound findings were significantly associated with complicated appendicitis in multivariate regression: an increased appendiceal diameter (OR = 1.3, p < .001), periappendiceal fat inflammation (OR = 1.5, p = 0.02), the presence of an appendicolith (OR = 1.7, p = 0.01) and a suspected perforation (OR = 6.0, p < .001) by the pediatric radiologist. For complicated appendicitis, an appendiceal diameter of more than 6 mm had the highest sensitivity (98%), while a sonographically suspected perforation showed the highest specificity (94%). Conclusion: Abdominal sonography by paediatric radiologists can differentiate between uncomplicated and complicated appendicitis in paediatric patients by using an increased appendiceal diameter, periappendiceal fat inflammation, the presence of an appendicolith and a suspected perforation as discriminatory markers. Advances in knowledge: This paper demonstrates expanded information on ultrasound, which is not only an essential tool for diagnosing appendicitis, but also a key method for distinguishing between different forms of appendicitis when performed by paediatric radiologists. Compared with previous studies, the crucial distinction features in our analysis are 1) the definition of gangrene and not primarily perforation as an acute complicated appendicitis enabling early decision-making by sonography and 2) a large number of patients in a particularly affected age group.

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“…As we consider developing our research programme into a multicentre effectiveness trial, it is important to consider other ongoing work in this field, particularly any work that has been completed since initiation of our feasibility study that may also be seeking to answer an identical or similar research question. Although there have been some recent reports of non-operative treatment in children with uncomplicated acute appendicitis, 19,[129][130][131][132][133][134][135] no trials have reported data beyond the pilot trial 13 described previously. However, we are aware of a number of ongoing randomised trials comparing appendicectomy with non-operative treatment for children with uncomplicated acute appendicitis, none of which has yet reported its outcomes.…”

Section: Other Ongoing Work In This Fieldmentioning

confidence: 99%

Conservative treatment for uncomplicated appendicitis in children: the CONTRACT feasibility study, including feasibility RCT

Hall

Sherratt

Eaton

et al. 2021

Health Technol Assess

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Background Although non-operative treatment is known to be effective for the treatment of uncomplicated acute appendicitis in children, randomised trial data comparing important outcomes of non-operative treatment with those of appendicectomy are lacking. Objectives The objectives were to ascertain the feasibility of conducting a multicentre randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of a non-operative treatment pathway with appendicectomy for the treatment of uncomplicated acute appendicitis in children. Design This was a mixed-methods study, which included a feasibility randomised controlled trial, embedded and parallel qualitative and survey studies, a parallel health economic feasibility study and the development of a core outcome set. Setting This study was set in three specialist NHS paediatric surgical units in England. Participants Children (aged 4–15 years) clinically diagnosed with uncomplicated acute appendicitis participated in the feasibility randomised controlled trial. Children, their families, recruiting clinicians and other health-care professionals involved in caring for children with appendicitis took part in the qualitative study. UK specialist paediatric surgeons took part in the survey. Specialist paediatric surgeons, adult general surgeons who treat children, and children and young people who previously had appendicitis, along with their families, took part in the development of the core outcome set. Interventions Participants in the feasibility randomised controlled trial were randomised to a non-operative treatment pathway (broad-spectrum antibiotics and active observation) or appendicectomy. Main outcome measures The primary outcome measure was the proportion of eligible patients recruited to the feasibility trial. Data sources Data were sourced from NHS case notes, questionnaire responses, transcribed audio-recordings of recruitment discussions and qualitative interviews. Results Overall, 50% (95% confidence interval 40% to 59%) of 115 eligible patients approached about the trial agreed to participate and were randomised. There was high acceptance of randomisation and good adherence to trial procedures and follow-up (follow-up rates of 89%, 85% and 85% at 6 weeks, 3 months and 6 months, respectively). More participants had perforated appendicitis than had been anticipated. Qualitative work enabled us to communicate about the trial effectively with patients and families, to design and deliver bespoke training to optimise recruitment and to understand how to optimise the design and delivery of a future trial. The health economic study indicated that the main cost drivers are the ward stay cost and the cost of the operation; it has also informed quality-of-life assessment methods for future work. A core outcome set for the treatment of uncomplicated acute appendicitis in children and young people was developed, containing 14 outcomes. There is adequate surgeon interest to justify proceeding to an effectiveness trial, with 51% of those surveyed expressing a willingness to recruit with an unchanged trial protocol. Limitations Because the feasibility randomised controlled trial was performed in only three centres, successful recruitment across a larger number of sites cannot be guaranteed. However, the qualitative work has informed a bespoke training package to facilitate this. Although survey results suggest adequate clinician interest to make a larger trial possible, actual participation may differ, and equipoise may have changed over time. Conclusions A future effectiveness trial is feasible, following limited additional preparation, to establish appropriate outcome measures and case identification. It is recommended to include a limited package of qualitative work to optimise recruitment, in particular at new centres. Future work Prior to proceeding to an effectiveness trial, there is a need to develop a robust method for distinguishing children with uncomplicated acute appendicitis from those with more advanced appendicitis, and to reach agreement on a primary outcome measure and effect size that is acceptable to all stakeholder groups involved. Trial registration Current Controlled Trials ISRCTN15830435. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 10. See the NIHR Journals Library website for further project information.

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Clinical recovery in children with uncomplicated appendicitis undergoing non-operative treatment: secondary analysis of a prospective cohort study

Cited by 20 publications

References 39 publications

Mitigating the impact of COVID-19 on children's surgery in Africa

Mitigating the impact of COVID-19 on children's surgery in Africa

Sonographic differentiation of complicated from uncomplicated appendicitis

Conservative treatment for uncomplicated appendicitis in children: the CONTRACT feasibility study, including feasibility RCT

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