Epidemiologic studies on acute appendicitis in children

Acute appendicitis is the most common surgical emergency in children. A considerable effort has been made to develop and improve treatment and outcomes. A PubMed search yields over 20 000 publications on appendicitis. Almost 8 000 abstracts are found if the search is restricted to children. Nevertheless, there are still controversies on the diagnostic work-up, treatment and outcome of acute appendicitis and there are many issues to be further explored. The diagnostic process behind the decision to explore the abdomen and remove the diseased appendix is evolving and novel diagnostic modalities are continuously introduced. Appendectomy as gold standard treatment for simple and complex appendicitis is challenged by non-operative treatment options. Even the fundamental concept of appendicitis as an inevitably progressive disease, ending up in perforation, has been challenged. We have not been able to fully understand nor significantly reduce associated complications including appendiceal perforation, intra-abdominal abscess, postoperative wound infection and adhesive small bowel obstruction, leading to significant morbidity and even death. The general aims of this thesis were to investigate the epidemiology of acute appendicitis in children and to identify factors important for optimising treatment and reducing morbidity. Paper I was a retrospective cohort study investigating the correlation between in-hospital surgical delay and the risk for perforated appendicitis. All 2 756 children operated for acute appendicitis in our institution 2006‒2013 were included in the study. Secondary outcome measures were markers of postoperative complications. In multivariate logistic regression analysis, increased time to surgery was not associated with increased risk for histopathologic perforation. There was no correlation between the timing of surgery and rate of postoperative wound infection, intra-abdominal abscess, reoperation, or readmission. In paper II, the epidemiology of acute appendicitis and appendectomy was investigated in a population-based cohort of Swedish children. Data was collected from the Swedish National Patient Register (NPR). 64 971 children registered in the NPR 1987‒2013 were eligible for the study. A rapidly declining incidence rate of childhood appendicitis was identified in Sweden over the study period, with significantly different trends comparing non-perforated and perforated appendicitis. Incidence rates differed between genders and between health care regions. Data did not reveal explanations on the aetiology of the findings. In paper III, the correlation between provision of care and outcome after appendectomy in children was investigated. Data from the NPR on 55 591 childhood appendectomies in Sweden 1987‒2009 were analysed. The risk of postoperative complications was significantly reduced in specialised paediatric surgical centers and in high caseload hospitals, compared to other hospitals. There were only seven deaths within 90 days of appendectomy in the cohort. We concluded that provision of care matters, and that reduced risks for complications may not only be achieved by centralisation to paediatric surgical centers but also by increasing hospital caseload of childhood appendicitis management in other settings

Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial

Objective: The aim of this study was to evaluate the feasibility and safety of nonoperative treatment of acute nonperforated appendicitis with antibiotics in children.Methods: A pilot randomized controlled trial was performed comparing nonoperative treatment with antibiotics versus surgery for acute appendicitis in children. Patients with imaging-confirmed acute nonperforated appendicitis who would normally have had emergency appendectomy were randomized either to treatment with antibiotics or to surgery. Follow-up was for 1 year.Results: Fifty patients were enrolled; 26 were randomized to surgery and 24 to nonoperative treatment with antibiotics. All children in the surgery group had histopathologically confirmed acute appendicitis, and there were no significant complications in this group. Two of 24 patients in the nonoperative treatment group had appendectomy within the time of primary antibiotic treatment and 1 patient after 9 months for recurrent acute appendicitis. Another 6 patients have had an appendectomy due to recurrent abdominal pain (n = 5) or parental wish (n = 1) during the follow-up period; none of these 6 patients had evidence of appendicitis on histopathological examination.Conclusions: Twenty-two of 24 patients (92%) treated with antibiotics had initial resolution of symptoms. Of these 22, only 1 patient (5%) had recurrence of acute appendicitis during follow-up. Overall, 62% of patients have not had an appendectomy during the follow-up period. This pilot trial suggests that nonoperative treatment of acute appendicitis in children is feasible and safe and that further investigation of nonoperative treatment is warranted

Complication rate after gastrostomy placement in children can be reduced by simple surgical steps

Aim To evaluate if the incidence of postoperative complications after gastrostomy placement is correlated to perioperative parameters or patient characteristics. Methods In this prospective observational study, children <18 years of age planned to receive a gastrostomy at partaking clinics between 2014 and 2019 were invited. Pre-, peri- and postoperative variables were collected and followed up 3 months postoperatively. Results Five hundred and eighty-two patients were included (median age: 26 months, median weight: 10.8 kg), mainly laparoscopic (52.0%) and push-PEG (30.2%) technique used. The incidence of complications was lower in the group of patients receiving a gastrostomy tube that was 2 mm longer than the gastrostomy canal (p < 0.001–0.025), and a thickness of 12 Fr (p < 0.001–0.009). These findings were confirmed by multivariate analysis also including operative technique, age and weight. Patients with oncological disease had significantly higher incidence of pain and infection but the lowest incidence of granulomas (p < 0.001–0.01). Conclusion This study indicates that a 12 Fr gastrostomy tube that is 2 mm longer than the gastrostomy canal is correlated with the lowest incidence of postoperative complications the first 3 months after surgery. Oncological patients had the lowest incidence of granulomas which probably is related to chemotherapy

Outcomes of biliary atresia in the Nordic countries – a multicenter study of 158 patients during 2005–2016

Background/purpose: Biliary atresia is the most common reason for newborn cholestasis and pediatric liver transplantation. Even after normalization of serum bilirubin after portoenterostomy, most patients require liver transplantation by adulthood due to expanding fibrosis. We addressed contemporary outcomes of biliary atresia in the Nordic countries. Methods: Data on center and patients characteristics, diagnostic practices, surgical treatment, adjuvant medical therapy after portoenterostomy, follow-up and outcomes were collected from all the Nordic centers involved with biliary atresia care during 2005–2016. Results: Of the 154 patients, 148 underwent portoenterostomy mostly by assigned surgical teams at median age of 64 (interquartile range 37–79) days, and 95 patients (64%) normalized their serum bilirubin concentration while living with native liver. Postoperative adjuvant medical therapy, including steroids, ursodeoxycholic acid and antibiotics was given to 137 (93%) patients. Clearance of jaundice associated with young age at surgery and favorable anatomic type of biliary atresia, whereas annual center caseload > 3 patients and diagnostic protocol without routine liver biopsy predicted early performance of portoenterostomy. The cumulative 5-year native liver and overall survival estimate was 53% (95% CI 45–62) and 88% (95% CI 83–94), respectively. Portoenterostomy age 3 patients were predictive for long-term native liver survival, while normalization of serum bilirubin after portoenterostomy was the major predictor of both native liver and overall 5-year survival. Conclusions: The outcomes of biliary atresia in the Nordic countries compared well with previous European studies. Further improvement should be pursued by active measures to reduce patient age at portoenterostomy