Çocuklarda akut apandisitin ameliyatsız tedavisi

Amaç: Akut apandisit için ameliyatsız tedaviyi ele alan çoğu çalışma yetişkinlere odaklanmıştır ve çocuklar için sınırlı veri mevcuttur. Akut komplikasyonsuz apandisitli çocuklarda başarılı ameliyatsız yönetimin sonuçlarını “ek kriterlerimiz” ile değerlendirmeyi ve hangi faktörlerin başarı oranını etkileyebileceğini ve hangi vakaların ameliyatsız tedaviye aday olabileceğini bulmayı amaçladık. Gereç ve yöntem: Akut komplikasyonsuz apandisit tanısı alan ve ameliyatsız tedavi uygulanan toplam 26 hasta retrospektif olarak yeniden değerlendirildi. Komplike olmayan apandisit tanımlaması semptomların süresine (<24 saat), klinik öyküye ve radyolojik bulgulara dayanıyordu. Radyolojik değerlendirme ultrasonografi ve bilgisayarlı tomografi ile yapıldı. Hastalara hastanede beş gün intravenöz antibiyotik kombinasyonu (sulbaktam/ampisilin, gentamisin, klindamisin) verildi; tedavi oral antibiyotik kombinasyonu (amoksisilin/klavulanat, metronidazol) ile 10 güne tamamlandı. Olguların ortalama takip süresi iki yıldı. Bulgular: Ortalama hasta yaşı ve takip süresi sırasıyla 10,42±3,65 yıl ve 30,15±5 aydı. Başvuru anındaki ortalama lökosit sayısı, C-reaktif protein (CRP) ve apendiks çapı değerleri 15,82±5,4×109/L, 20,38±33,4mg/dL ve 7,87±1,4 mm idi. Hastaların hiçbirinde erken başarısızlık, komplikasyon veya yan etki görülmedi. İzlemde sadece bir olguda (%4) tekrarlayan apandisit gelişti ve laparoskopik apendektomi ile tedavi edildi. Sonuç: Çocuklarda akut komplike olmayan apandisitin ameliyatsız yönetimi, kriterlerimize göre uzun vadeli sonuçlara göre tatmin ediciydi ve başlangıç başarı oranları mükemmeldi.

Anahtar Kelimeler:

Akut apandisit, apandisit, çocuk, konservatif tedavi, ameliyatsız tedavi

Non-Operative management of acute appendicitis in children

Purpose: Most studies addressing non-operative management for acute appendicitis have focused on adults, and there are limited data available for children. We aimed to evaluate the results of successful non-operative management in children with acute uncomplicated appendicitis with our “additional criteria” and find which factors could be affecting the success rate and which cases could be candidates for non-operative management. Materials and methods: A total of 26 patients who were diagnosed with acute uncomplicated appendicitis and received non-operative management were re-evaluated retrospectively. Defining uncomplicated appendicitis was based on the duration of symptoms (<24 hours), clinical history, and radiologic findings. The radiologic evaluation was based on ultrasonography and computed tomography. The patients received an intravenous antibiotic combination (sulbactam/ampicillin, gentamicin, clindamycin) for five days at the hospital; the treatment was completed after 10 days with an oral antibiotic combination (amoxicillin/clavulanate, metronidazole). The cases have a follow-up period of up to two years. Results: The mean patient age and follow-up time were 10,42±3,65 years and 30,15±5 months, respectively. The mean leukocyte count, C-reactive protein (CRP), and appendix diameter values were 15,82±5,4×109/L, 20,38±33,4mg/dL, and 7.87±1.4 mm on admission. None of the patients had an early failure, complication, or adverse event. Recurrent appendicitis occurred in only one case (4%) that was treated by laparoscopic appendectomy during the follow-up. Conclusion: Non-operative management for acute uncomplicated appendicitis in children regarding long-term outcomes with our criteria was satisfactory and initial success rates were excellent.

Keywords:

Acute appendicitis, appendectomy, children, conservative treatment, non-operative management,

PDF

___

1. Ashcraft KW, Holcomb GW, Murphy JP, et al, eds. Ashcraft's pediatric surgery. 6th ed. London: Saunders/Elsevier; 2014
2. Scott A, Lee SL, DeUgarte DA, Shew SB, Dunn JCY, Shekherdimian S. Nonoperative Management of Appendicitis. Clin Pediatr (Phila) 2018;57:200-204. https://doi.org/10.1177/0009922817696465
3. Svensson JF, Hall NJ, Eaton S, Pierro A, Wester T. A review of conservative treatment of acute appendicitis. Eur J Pediatr Surg 2012;22:185-194. https://doi.org/10.1055/s-0032-1320014
4. Abeş M, Petik B, Kazil S. Nonoperative treatment of acute appendicitis in children. J Pediatr Surg 2007;42:1439-1442. https://doi.org/10.1016/j.jpedsurg.2007.03.049
5. Armstrong J, Merritt N, Jones S, Scott L, Bütter A. Non-operative management of early, acute appendicitis in children: is it safe and effective? J Pediatr Surg 2014;49:782-785. https://doi.org/10.1016/j.jpedsurg.2014.02.071
6. Koike Y, Uchida K, Matsushita K, et al. Intraluminal appendiceal fluid is a predictive factor for recurrent appendicitis after initial successful non-operative management of uncomplicated appendicitis in pediatric patients. J Pediatr Surg 2014;49:1116-1121. https://doi.org/10.1016/j.jpedsurg.2014.01.003
7. Steiner Z, Buklan G, Stackievicz R. A role for conservative antibiotic treatment in early appendicitis in children. J Pediatr Surg 2015;50:1566-1568. https://doi.org/10.1016/j.jpedsurg.2015.04.008
8. Gorter RR, van der Lee JH, Cense HA, et al. Initial antibiotic treatment for acute simple appendicitis in children is safe: Short-term results from a multicenter, prospective cohort study. Surgery 2015;157:916-923. https://doi.org/10.1016/j.surg.2015.01.008
9. Minneci PC, Mahida JB, Lodwick DL, et al. Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis. JAMA Surg 2015;151:408-415. https://doi.org/10.1001/jamasurg.2015.4534
10. Tanaka Y, Uchida H, Kawashima H, et al. Long-term outcomes of operative versus nonoperative treatment for uncomplicated appendicitis. J Pediatr Surg 2015;50:1893-1897. https://doi.org/10.1016/j.jpedsurg.2015.07.008
11. Svensson JF, Patkova B, Almström M, 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. https://doi.org/10.1097/sla.0000000000000835
12. Hartwich J, Luks FI, Watson Smith D, et al. Nonoperative treatment of acute appendicitis in children: A feasibility study. J Pediatr Surg 2016;51:111-116. https://doi.org/10.1016/j.jpedsurg.2015.10.024
13. Caruso AM, Pane A, Garau R, et al. Acute appendicitis in children: not only surgical treatment. J Pediatr Surg 2017;52:444-448. https://doi.org/10.1016/j.jpedsurg.2016.08.007
14. Steiner Z, Buklan G, Stackievicz R, et al. Conservative treatment in uncomplicated acute appendicitis: reassessment of practice safety. Eur J Pediatr 2017;176:521-527. https://doi.org/10.1007/s00431-017-2867-2
15. Steiner Z, Buklan G, Gutermacher M, Litmanovitz I, Landa T, Arnon S. Conservative antibiotic treatment for acute uncomplicated appendicitis is feasible. Pediatr Surg Int 2018;34:283-288. https://doi.org/10.1007/s00383-018-4226-4
16. Mudri M, Coriolano K, Bütter A. Cost analysis of nonoperative management of acute appendicitis in children. J Pediatr Surg 2017;52:791-794. https://doi.org/10.1016/j.jpedsurg.2017.01.050
17. Rentea RM, St Peter SD. Contemporary Management of Appendicitis in Children. Adv Pediatr 2017;64:225-251. https://doi.org/10.1016/j.yapd.2017.03.008
18. Rentea RM, Peter SDS, Snyder CL. Pediatric appendicitis: state of the art review. Pediatr Surg Int 2017;33:269-283. https://doi.org/10.1007/s00383-016-3990-2 19. Styrud J, Eriksson S, Nilsson I, et al. Appendectomy versus antibiotic treatment in acute appendicitis. A prospective multicenter randomized controlled trial. World J Surg 2006;30:1033-1037. https://doi.org/10.1007/s00268-005-0304-6
20. Maita S, Andersson B, Svensson JF, Wester T. Nonoperative treatment for nonperforated appendicitis in children: a systematic review and meta-analysis. Pediatr Surg Int 2020;36:261-269. https://doi.org/10.1007/s00383-019-04610-1
21. Mosuka EM, Thilakarathne KN, Mansuri NM, et al. A systematic review comparing nonoperative management to appendectomy for uncomplicated appendicitis in children. Cureus 2021;19;13:e18901. https://doi.org/10.7759/cureus.18901
22. Glass CC, Rangel SJ. Overview and diagnosis of acute appendicitis in children. Semin Pediatr Surg 2016;25:198-203. https://doi.org/10.1053/j.sempedsurg.2016.05.001
23. Partrick DA, Janik JE, Janik JS, Bensard DD, Karrer FM. Increased CT scan utilization does not improve the diagnostic accuracy of appendicitis in children. J Pediatr Surg 2003;38:659-62. https://doi.org/10.1016/jpsu.2003.5017
24. Glass CC, Saito JM, Sidhwa F, et al. Diagnostic imaging practices for children with suspected appendicitis evaluated at definitive care hospitals and their associated referral centers. J Pediatr Surg 2016;51:912-916. https://doi.org/10.1016/j.jpedsurg.2016.02.055
25. Kotagal M, Richards MK, Chapman T, et al. Improving ultrasound quality to reduce computed tomography use in pediatric appendicitis: the Safe and Sound campaign. Am J Surg 2015;209:896-900. https://doi.org/10.1016/j.amjsurg.2014.12.029
26. Perez Otero S, Metzger JW, Choi BH, et al. It's time to deconstruct treatment-failure: A randomized controlled trial of nonoperative management of uncomplicated pediatric appendicitis with antibiotics alone. J Pediatr Surg 2022;57:56-62. https://doi.org/10.1016/j.jpedsurg.2021.09.024
27. Bachur RG, Lipsett SC, Monuteaux MC. Outcomes of Nonoperative Management of Uncomplicated Appendicitis. Pediatrics 2017;140:20170048. https://doi.org/10.1542/peds.2017-0048
28. Georgiou R, Eaton S, Stanton MP, Pierro A, Hall NJ. Efficacy and safety of nonoperative treatment for acute appendicitis: a meta-analysis. Pediatrics 2017;139:e20163003. https://doi.org/10.1542/peds.2016-3003
29. Gorter RR, The SML, Gorter Stam MAW, et al. Systematic review of nonoperative versus operative treatment of uncomplicated appendicitis. J Pediatr Surg 2017;52:1219-1227. https://doi.org/10.1016/j.jpedsurg.2017.04.005
30. Kessler U, Mosbahi S, Walker B, et al. Conservative treatment versus surgery for uncomplicated appendicitis in children: a systematic review and meta-analysis. Arch Dis Child 2017;102:1118-1124. https://doi.org/10.1136/archdischild-2017-313127