Comparison of clinical and histological diagnosis in children with classic and laparoscopic appendectomy

Abstract

Abdominalna bol je jedan od glavnih razloga hitnog prijema, a akutni apendicitis je jedno od najčešćih kirurških hitnih stanja u dječjoj dobi. Postaviti dijagnozu akutnog apendicitisa u pedijatrijskoj populaciji i donijeti odluku o apendektomiji, izazov je i dan danas, čak i za iskusne kliničare. Naime, dijagnoza je sinteza podataka dobivenih iz anamneze, kliničkog pregleda, laboratorijskih vrijednosti te radioloških pretraga. Neprepoznata dijagnoza ili odgađanje kirurškog zahvata može rezultirati komplikacijama kao što su perforacija, apsces i peritonitis. S druge strane, u stanjima koja samo nalikuju akutnom apendicitisu odluka kliničara o apendektomiji vodi ka uklanjanju inocentnih crvuljaka u 15-30% (1,65). Cilj ovog rada je pružiti usporedbu kliničke i histološke dijagnoze te ostalih vrednovanih parametara između dviju skupina djece; laparoskopski i klasično apendektomirane. U radu je analizirano 330 djece sa sumnjom na akutni apendicitis, u dobi od dvije do 19 godina, koja su u razdoblju od 2013. do 2016. hospitalizirana i liječena na Zavodu za dječju kirurgiju u Kliničkom bolničkom centru Zagreb. Omjer dječaka i djevojčica je 1.34:1. Sva su djeca apendektomirana; njih 83.6% laparoskopski, a 16.4% klasičnom operacijom, kojima su pridruženi i slučajevi kada je došlo do konverzije iz laparoskopske u klasičnu apendektomiju. Podudaranje makroskopskog nalaza operatera i mikroskopskog nalaza patologa ne bilježi se u velikom postotku. U skupini laparoskopsko apendektomiranih nalazi su se podudarali u 46.2%, a kod klasično apendektomiranih u 35.2% slučajeva. Veće vrijednosti Alvarado bodova (≥7 u prosjeku) upućuju na flegmonozni ili gangrenozni stadij akutnog apendicitisa. Perforacija crvuljka rjeđa je pojava kod laparoskopsko apendektomiranih (10.2% naspram 32%). Od svih inocentnih crvuljaka, njih 90% pronađeno je kod djece koja su laparoskopsko apendektomirana. K tomu je negativna apendektomija češća pojava među djevojčicama (19.9%) nego li među dječacima (6.3%). Peritiflitički apsces kao posljedica perforacije, češći je intraoperativni nalaz u skupini KA (66.7% svih peritiflitičkih apscesa). Komplikacije apendektomije, infekcija kirurške rane te instraabdominalni apsces pojavljuju se po sličnom obrascu; vrlo rijetko i bez statistički značajne razlike među skupinama.Abdominal pain is one of the most common causes of emergency department admissions and acute appendicitis is one of the most frequent surgical emergencies in children. To diagnose acute appendicitis and make a decision about appendectomy in the pediatric population is still challenging nowadays, even for experienced clinicians. In fact, the clinical diagnosis represents a synthesis of the medical history, physical examination, laboratory tests and radiographic imaging. An unrecognized diagnosis or delayed surgical removal of an inflamed appendix may result in complications such as perforation, abscess and peritonitis. On the other hand, due to clinical conditions that are similar to acute appendicitis, clinicians' decisions about appendectomy lead to an unnecessary removal of the appendix in 15-30% of cases (1,65). The aim of this study was a comparison of the clinical and histological diagnosis, and other valued parameters between two groups of children: those who underwent laparoscopic and those who had a classic appendectomy. 330 children aged two to 19 years, who were admitted to the Department of Pediatric Surgery at the University Hospital Centre Zagreb, in the period between 2013 and 2016 under suspicion of acute appendicitis, were analyzed in this study. The boys to girls ratio was 1.34:1. All of the children underwent the appendectomy; 83.6% of them had a laparoscopic, and 16.4% a classic procedure. The latter group also comprised those cases who were converted from laparoscopic to classic appendectomy. Concordance between the macroscopic surgical and microscopic pathological diagnoses was low. In the group of laparoscopic appendectomy, the diagnoses were correlated in 46.2%, and among those who underwent classic appendectomy in 35.2% of the cases. Higher Alvarado scores (average ≥7) point to phlegmonous or gangrenous acute appendicitis. A perforated appendix was less common among children who underwent laparoscopic appendectomy (10.2% in comparison with 32% in the other group). 90% of all innocent appendices were found in the laparoscopic appendectomy group. Furthermore, the negative appendectomy rate was higher among girls (19.9%) than boys (6.3%). Periappendiceal abscess after perforation was a more common intraoperative assessment in the classic appendectomy group (66.7% of all abscesses). Complications associated with appendectomy, infection of the surgical site and intraabdominal abscess, had the same incidence pattern – they occured rarely and with no statistically significant difference between the groups