Nonoperative Management of Appendiceal Phlegmon or Abscess with an Appendicolith in Children

Transcription

1 J Gastrointest Surg (2013) 17: DOI /s ORIGINAL ARTICLE Nonoperative Management of Appendiceal Phlegmon or Abscess with an Appendicolith in Children Hai-Lan Zhang & Yu-Zuo Bai & Xin Zhou & Wei-Lin Wang Received: 18 October 2012 / Accepted: 2 January 2013 / Published online: 12 January 2013 # 2013 The Society for Surgery of the Alimentary Tract Abstract Background The optimal treatment of appendiceal phlegmon or abscess with an appendicolith is controversial. This study aimed to evaluate outcomes and prognosis of nonoperative management of appendiceal phlegmon or abscess with an appendicolith in children. Methods From 2007 to 2011, 105 children with appendiceal phlegmon or abscess who were treated nonoperatively without interval appendectomy were reviewed. Average follow-up of subjects was 2.4 years. Data were compared between subjects with and without an appendicolith or persistent presence and disappearance of an appendicolith. Results The success rate for nonoperative therapy for appendiceal phlegmon or abscess with appendicolith was 95.9 %. The risk of recurrent appendicitis in appendiceal phlegmon or abscess with appendicolith (19.1 %) was higher than that without appendicolith (8.9 %, P=0.132). The rate of appendicolith disappearance during follow-up was 80.9 %. The persistent presence of an appendicolith was associated with a significantly higher recurrence rate (66.7 %) compared with appendicolith disappearance (7.9 %, P<0.05). Conclusion Appendiceal phlegmon or abscess with an appendicolith can be managed nonoperatively, and most appendicoliths can be resolved. Persistent presence of an appendicolith is a significant risk factor for recurrent appendicitis. Interval appendectomy is recommended for persistent presence of appendicolith, but is not indicated in cases without appendicolith or appendicolith disappearance. Keywords Appendiceal Phlegmon. Appendiceal Abscess. Appendicolith. Nonoperative Management. Children Introduction The symptoms and physical signs of acute appendicitis may overlap with other gastrointestinal or genitourinary diseases leading to a missed or delayed clinical diagnosis, especially in children. The appendiceal phlegmon or abscess (APA) at presentation occurs in about 30 to 60 % of children. 1, 2 The presence of an appendicolith is closely associated with APA. 3 Current researches on APA with an appendicolith are rare and controversial. The debates predominantly focus H.-L. Zhang : Y.-Z. Bai : X. Zhou : W.-L. Wang (*) Department of Pediatric Surgery, Shengjing Hospital of China Medical University, No. 36 Sanhao St., Heping District, Shenyang, China wangwl@sj-hospital.org on the effects of an appendicolith, the success rate of nonoperative management, and the necessity of interval appendectomy (IA). The presence of an appendicolith might predict failure of nonoperative management of APA, and immediate appendectomy may be a better choice. 4 However, some studies found no correlation between clinical outcomes and the presence of appendicolith. 5 Recent studies 6, 7 indicated that an appendicolith was a risk factor for recurrent appendicitis and patients should receive IA; however, immediate appendectomy was not suggested considering the difficulty of technique associated with appendectomy before the inflammatory process completely subsided and the relatively mild course of recurrent appendicitis. It is important to study the relationship of APA with an appendicolith in order to understand the clinical outcomes of nonoperative treatment and the necessity of IA to prevent recurrence. To our knowledge, confirming the persistent presence or disappearance of appendicolith in APA by subsequent computed tomography (CT) scans and development of recurrent appendicitis has not been systematically

2 J Gastrointest Surg (2013) 17: reported. The purposes of this study were to evaluate the outcomes and prognosis of nonoperative treatment of APA with an appendicolith in children, with emphasis on the success rate and the need for IA. Patients and Methods This retrospective study was approved by the Ethics Committee at Shengjing Hospital of China Medical University. From January 2007 to December 2011, 170 pediatric patients ( 14 years old) presented to our hospital with a clinical diagnosis of APA. Among them, 48 were treated by immediate appendectomy or surgical drainage because of extensive peritonitis, apparent intestinal obstruction, and shorter duration of symptoms ( 3 days). Another 122 children with APA who underwent attempted initial nonoperative treatment were reviewed. Exclusion criteria included children with incomplete follow-up and interval appendectomy after successful nonoperative management. A total of 105 patients met the study criteria. Data collected included demographics, duration of symptoms, common symptoms (e.g., pain, fever, vomiting, diarrhea), physical signs (e.g., tenderness, rebound, rigidity), white blood cell (WBC) counts, C-reactive protein (CRP) values, antibiotics administered, length of stay (LOS), ultrasonography (USG), and CT scan findings. CT scans were performed on a Siemens Sensation 64 CT (Siemens Medical Solutions, Forchheim, Germany) or a Philips Brilliance 64 CT (Philips Medical Systems, Cleveland, USA). In order to decrease children s exposure to radiation, our hospital keeps the radiation dose as low as possible without comprising the quality of CT images. Periappendiceal abscesses were not generally drained unless the condition of patients did not improve or abscesses gradually increased. Nonoperative therapy was considered a failure in those patients who received appendectomy during the initial hospitalization for nonsurgical therapy because of the deterioration of clinical symptoms and signs or intestinal obstruction. Based on the presence or absence of an appendicolith on admission CT imaging, children were divided into two groups: 49 patients with appendicolith (AC group) and 56 patients with no appendicolith (NA group). The conservatively treated patients were given intravenous, broadspectrum antibiotics, and intrarectal suppositories (gentamicin and metronidazole). The therapy was continued for at least 7 days. When the patients improved, USG or CT was again performed and reexamined. The absence of an appendicolith must be confirmed by CT imaging, even if USG indicated no appendicolith of the appendix. If regression of appendiceal inflammation was seen on USG or CT and patients remained afebrile, with improved physical signs and lower WBC and CRP, they were discharged home with oral broad-spectrum antibiotics. The patients returned to our pediatric clinic after 1, 2, and 3 or 4, 6, and 12 months, respectively. After the first year, the patients were examined once every year. Each child was followed for an average of 2.4 years in our clinic. Statistical Analysis Data are presented as mean ± standard deviation. The statistical analyses were performed using Student s t test or chisquare test with Fisher s exact examination. A P value of less than 0.05 was considered as significant. The statistical calculations were performed using SPSS software version 13.0 (SPSS Inc., Chicago, IL, USA). Results Among 105 children who met the study criteria, 49 children in the AC group and 56 in the NA group were treated nonsurgically. The AC group included 24 males and 25 females with an average age of 7.1±3.7 years. The NA group included 30 males and 26 females with an average age of 6.4±3.5 years. Results are summarized in Table 1. In the AC group, duration of symptoms was 9.3± 4.8 days. No significant differences were found between the AC and NA groups when comparing common symptoms such as abdominal pain (100 vs. 100 %), fever (81.6 vs %), vomiting (51.0 vs %), and diarrhea (42.9 vs %). Excluding two children who underwent appendectomy because of intestinal obstruction, LOS was 12.5± Table 1 Clinical data between the AC group and NA group AC (n=49) NA (n=56) P value Sex (male/female) 24:25 15: Age (years) 7.1± ± Duration of symptoms 9.3± ± Pain 49 (100 %) 56 (100 %) Fever 40 (81.6 %) 45 (80.4 %) Localized peritonitis 35 (71.4 %) 3 1(55.4 %) WBC 20.2± ± CRP 122.9± ± Inflammatory area (cm 2 ) 34.5± ± Percutaneous drainage 2 (4.1 %) 1 (1.8 %) LOS (excluding 12.5± ± appendectomy) Overall success 47 (95.9 %) 56 (100 %) Recurrent appendicitis (excluding appendectomy) 9/47 (19.1 %) 5/56 (8.9 %) AC appendicolith, NA no appendicolith

3 768 J Gastrointest Surg (2013) 17: Fig. 1 a The admission CT scan of a 13-year-old boy showed an appendiceal phlegmon formation and a dilated appendix with an appendicolith. b An appendicolith disappeared after 12 days of nonoperative management 6.0 days in the AC group. The rate of localized peritonitis was slightly higher in the AC group (71.4 %) than in the NA group (55.4 %). Similarly, WBC (20.2±5.4 vs. 17.6±5.2) and CRP (122.9±66.7 vs ±64.6) values were slightly higher and mean inflammatory areas of APA (34.5±23.4 vs. 26.6±18.8) on USG or CT scan were slightly larger in the AC group compared to those in the NA group. However, these data did not reach statistical significance. Two patients in the AC and one patient in the NA group underwent CTguided percutaneous drainage and received successful conservative therapy. In the AC group, two children underwent appendectomy and surgical drainage because of aggravated intestinal obstruction occurring between 8 and 12 days after initial nonsurgical management. All children in the NA group were treated successfully with nonoperative treatment. There were no statistically significant differences between the AC and NA groups (95.9 vs. 100 %) in the overall success rate for nonoperative management of APA. All children were followed up for an average of 2.4 years (range, 0.5 to 5.5 years). There was no significant difference in the average follow-up time between the NA and AC groups (2.5±1.4 vs. 2.2±1.5, P=0.358). Five patients had recurrent appendicitis in the NA group between 2 months and 2 years after initial conservative treatment. Of these, one patient had another APA and was treated nonoperatively again, receiving IA after 3 months. In the AC group, nine patients had recurrent appendicitis between 1 and 10 months after initial treatment. Of these, four children had another APA. Two patients with second APAs received appendectomy immediately, whereas the remaining two patients had IA between 2 and 3 months after another course of conservative treatment. Two cases had appendicoliths outside the appendix in the appendectomy. The risk of recurrence in the AC group (19.1 %) was higher than that in the NA group (8.9 %), but without statistical significance. In the AC group, the appendicolith disappeared in 38 children and presented persistently in APA in nine children during the follow-up period. Excluding two patients who underwent appendectomy because of intestinal obstruction, the rate of disappeared appendicolith was 80.9 %. Based on whether appendicolith disappeared or persisted, the patients in the AC group were divided into two subgroups: appendicolith disappearance and appendicolith persistent presence. Among the appendicolith disappearance group, 57.9 % of appendicoliths (22/38) disappeared during the initial hospitalization (Figs. 1 and 2). The earliest appendicolith resolution was the fourth day of conservative management, while most appendicoliths resolved within 6 14 days. The disappearance of an appendicolith in 15 children was found in the first month of follow-up and another appendicolith disappeared in the fourth month of follow-up (Fig. 3). Under similar circumstances of age, symptomatic duration and mean inflammatory area, risk of localized peritonitis, WBC and CRP values, and LOS were slightly higher in the appendicolith persistent presence subgroup than in the appendicolith disappearance subgroup (Table 2). Three patients with appendicolith disappearance had recurrent appendicitis, for a 7.9 % recurrence rate. However, two patients with persistent appendicolith had recurrent appendicitis and four recurrent APAs. The Fig. 2 a The initial CT image with intravenous contrast medium of a 2-year-old girl showed an appendicolith within a multilocular appendiceal abscess. b Intravenous contrast CT scan revealed that the appendiceal abscess was absorbed and the appendicolith was resolved after 17 days of nonoperative management

4 J Gastrointest Surg (2013) 17: Fig. 3 a The initial intravenous contrast image of a 7-year-old boy showed an appendicolith within the multilocular gas-containing appendiceal abscess with an enhancing rim. b The abscess was smaller and the appendicolith was still present on contrast-enhanced image after 7 days when he was discharged. c The inflammatory change of the right lower quadrant and the appendicolith disappeared on the CT scan at the fourth month of follow-up persistent presence of an appendicolith was associated with a significantly higher rate of recurrent appendicitis (66.7 %) compared with appendicolith disappearance, representing a statistically significant difference (P<0.05). Discussion An appendicolith, or fecalith, is composed of inspissated fecal material, mucus with entrapped calcium phosphate, and inorganic salts. With the increased use of CT scans, the appendicoliths are detected in 40 to 50 % of children who present with a clinical suspicion of acute appendicitis. 8, 9 The appendicolith has long been implicated as an important cause of acute appendicitis, especially in APA. 10, 11 Current surgical guidelines advise nonoperative management of APA in children. However, the optimal treatment of APA with an appendicolith is not well established. When an appendicolith is present in APA, it was believed to predict failure of conservative therapy and immediate appendectomy was suggested. 4 However, in our review of children with an appendicolith in APA, the success rate of nonoperative treatment was 95.9 %, without a statistically significant difference compared to the NA group. This Table 2 Clinical data between the appendicolith persistent presence subgroup and appendicolith disappearance subgroup APs (n=9) ADs (n=38) P value Age (years) 6.7± ± Duration of symptoms 9.7± ± Localized peritonitis 8 (88.9 %) 25 (65.8 %) WBC 22.2± ± CRP 143.5± ± Inflammatory area (cm 2 ) 34.6± ± LOS 16.1± ± Recurrent appendicitis 6 (66.7 %) 3 (7.9 %) 0.001* APs appendicolith persistent presence subgroup, ADs appendicolith disappearance subgroup *P<0.05 indicates that APA with an appendicolith can be nonsurgically managed and immediate appendectomy is not necessary. Our results are consistent with other studies of APA in children, and immediate appendectomy might encounter difficulties because of distorted anatomy, inflammatory adhesion, closing the appendiceal stump, and severe postoperative complications. During the mean 2.4 years of follow-up, the recurrence rate of the AC group was 19.1 %. This is similar to previous research on the mean risk of recurrent appendicitis after the conservative management of APA in children. 15 In our research, the recurrence rate was slightly higher compared to that of the NA group but without statistical significance. During the follow-up period, we were surprised that the higher recurrence rate was closely associated with the persistent presence of an appendicolith in APA, but not with its disappearance. In the AC group, the appendicolith disappeared on subsequent CT scans in 38 of 47 children who had the presence of appendicolith on admission CT exams. Among them, the appendicoliths of 22 (57.9 %) patients were absent at the end of the initial hospitalization. Until first month of followup, 97.4 % (37/38) of appendicoliths were resolved. Hence, the first month of follow-up was vital when the patient was discharged with the presence of appendicolith at last reexamination. The interesting aspect was that the appendicolith in APA most likely resolved spontaneously just as in simple appendicitis or normal appendix. 10 The appendicolith still existed in the appendiceal lumen even if the appendix in most cases had perforated with APA. As seen in our results, the perforated appendix should likely be able to expel an appendicolith from its lumen depending on peristaltic movement. The rate of recurrent appendicitis after appendicolith disappearance was 7.9 %, which was similar to the recurrence rate of the NA group. Several reviews also indicated that IA was not necessary because of a lower recurrence rate When IA is performed, patients are exposed to an % complication risk in order to prevent a recurrence of appendicitis in less than 10 % of patients. 17, 18 Also, patients who experience recurrent appendicitis usually

5 770 J Gastrointest Surg (2013) 17: exhibit a milder clinical course at recurrence. 19 In the no appendicolith and appendicolith disappearance groups, only one child had another APA and IA after receiving conservative management again. The other children with recurrent appendicitis received appendectomy immediately with zero morbidity. Nine children in our series had persistent presence of an appendicolith during the follow-up period. Among them, two patients had recurrent appendicitis and four had recurrent APA. The recurrence rate was 66.7 % in the appendicolith persistent presence subgroup, which was a 8.4 relative risk (66.7 vs. 7.9 %) for recurrent appendicitis compared with the appendicolith disappearance with APA, and recurrent APA was accounting for 66.7 %. The four children with recurrent APA returned on months 3, 4, 3, and 7, respectively. This indicated that IA was able to prevent recurrent complicated appendicitis because the recurrence was often after 3 months of initial conservative management. These data suggest that the persistent presence of an appendicolith increases recurrent risk in children with APA. IA was recommended to prevent recurrence in patients with persistent presence of appendicolith in APA. Our study has some limitations. One limitation is that the data were retrospectively collected. This may have resulted in some degree of bias. Another limitation is that the number of patients with persistent appendicolith was lower than expected because most cases resolved. Further large-scale, prospective trials are needed to validate our conclusion about the optimal treatment of APA with an appendicolith. Conclusion APA with an appendicolith can be managed nonoperatively without immediate appendectomy. Most appendicoliths present on admission CT scans will resolve. The persistent presence of an appendicolith rather than appendicolith presence alone was a significant risk factor for recurrent appendicitis in APA. IA was recommended for the persistent presence of an appendicolith in APA, but IA is not indicated in APA cases without appendicolith or disappearance of appendicolith. References 1. Nance ML, Adamson WT, Hedrick HL. Appendicitis in the young child: a continuing diagnostic challenge. Pediatr Emerg Care 2000;16: Pearl RH, Hale DA, Molloy M, Schutt DC, Jaques DP. Pediatric appendectomy. J Pediatr Surg 1995;30: Alaedeen DI, Cook M, Chwals WJ. Appendiceal fecalith is associated with early perforation in pediatric patients. J Pediatr Surg 2008;43: Aprahamian CJ, Barnhart DC, Bledsoe SE, Vaid Y, Harmon CM. Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences. J Pediatr Surg 2007;42: Levin T, Whyte C, Borzykowski R, Han B, Blitman N, Harris B. Nonoperative management of perforated appendicitis in children: can CT predict outcome? Pediatr Radiol 2007;37: Tsai HM, Shan YS, Lin PW, Lin XZ, Chen CY. Clinical analysis of the predictive factors for recurrent appendicitis after initial nonoperative treatment of perforated appendicitis. Am J Surg 2006;192: Ein SH, Langer JC, Daneman A. Nonoperative management of pediatric ruptured appendix with inflammatory mass or abscess: presence of an appendicolith predicts recurrent appendicitis. J Pediatr Surg 2005;40: Friedland JA, Siegel MJ. CT appearance of acute appendicitis in childhood. AJR Am J Roentgenol 1997;168: Lowe LH, Penney MW, Scheker LE, Perez R Jr, Stein SM, Heller RM, Shyr Y, Hernanz-Schulman M. Appendicolith revealed on CT in children with suspected appendicitis: how specific is it in the diagnosis of appendicitis? AJR Am J Roentgenol 2000;175: Rabinowitz CB, Egglin TK, Beland MD, Mayo-Smith WW. Outcomes in 74 patients with an appendicolith who did not undergo surgery: is follow-up imaging necessary? Emerg Radiol 2007;14: Williams RF, Blakely ML, Fischer PE, Streck CJ, Dassinger MS, Gupta H, Renaud EJ, Eubanks JW, Huang EY, Hixson SD, Langham MR. Diagnosing ruptured appendicitis preoperatively in pediatric patients. J Am Coll Surg 2009;208: Roach JP, Partrick DA, Bruny JL, Allshouse MJ, Karrer FM, Ziegler MM. Complicated appendicitis in children: a clear role for drainage and delayed appendectomy. Am J Surg 2007;194: Gillick J, Velayudham M, Puri P. Conservative management of appendix mass in children. Br J Surg 2001;88: Erdoğan D, Karaman I, Narci A, Karaman A, Cavuşoğlu YH, Aslan MK, Cakmak O. Comparison of two methods for the management of appendicular mass in children. Pediatr Surg Int 2005;21: Hall NJ, Jones CE, Eaton S, Stanton MP, Burge DM. Is interval appendicectomy justified after successful nonoperative treatment of an appendix mass in children? A systematic review. J Pediatr Surg 2011;46: Meshikhes AW. Management of appendiceal mass: controversial issues revisited. J Gastrointest Surg 2008;12: Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis. Ann Surg 2007;246: Willemsen PJ, Hoorntje LE, Eddes EH, Ploeg RJ. The need for interval appendectomy after resolution of an appendiceal mass questioned. Dig Surg 2002;19: Dixon MR, Haukoos JS, Park IU, Oliak D, Kumar RR, Arnell TD, Stamos MJ. An assessment of the severity of recurrent appendicitis. Am J Surg 2003;186: