Non-Surgical and Surgical Treatment of Acute Appendicitis in Children. Literature Review of the Last 5 Years
No Thumbnail Available
Date
2022
Authors
Journal Title
Journal ISSN
Volume Title
Publisher
Rīgas Stradiņa universitāte
Rīga Stradiņš University
Rīga Stradiņš University
Abstract
Akūts apendicīts joprojām ir viena no visbiezākām akūtām bērnu ķirurģiskām slimībām, kā arī svarīgs iemesls bērnu nāvēm un lieliem veselības sistēmas izdevumiem, pārsvarā saistītiem ar komplicēto apendicītu. Ilgu laiku apendicīts bija ārstēts tikai ar apendektomiju, bet mūsdienas antibiotiķu terapija ir kļuvusi populārāka savas pieejamības dēļ. Ir teorijas, ka nekomplicēts apendicīts ne vienmēr izraisa perforāciju. Diemžēl, pētnieciskie pierādījumi pediatriskajā laukā joprojām ir ierobežoti, salīdzinot ar pieaugušiem. Tāpēc dažas klīnikas ir izstrādājušas pašu vadlīnijas.
Šī literatūras apskata mērķis ir atrast un apkopot jaunāku informāciju par apendicīta diagnostiku un ārstēšanu pediatriskajā populācijā, kā arī piedāvāt pierādījumus par klīnisko lēmumu pieņemšanu starp operatīvo un neoperatīvo apendicīta ārstēšanu. Šajā apskatā ir lietota literatūra no tiešsaistes datubāzēm, izdota starp 2017(2016) un 2021 gadiem.
Literatūrā piedāvātie komplicēta apendicīta parametri ir: simptomu ilgums >24/48 st., vecums <5 g., ķermeņa temperatūra >38C, izteikta leikocitoze, neitrofīlija, hiponatrēmija un paaugstināts prokalcitonīns. Nekomplicētas slimības parametri ir: sāpes vēderā <48 st., apendiksa diametrs <1,1 cm (radiogrāfiski) un viegla leikocitoze.
Pirmais randomizēts pētījums ar ar vismaz piecu gadu kontroli ar salīdzinājumu starp neoperatīvo ārstēšanu un apendektomiju akūtām neperforētām apendicītam bija izstrādāts Patkova et. al. (2020). Papildus tam, arī neliels retrospektīvo vai nerandomizēto pētījumu skaits bija izstrādāts šajos gados, kā arī meta-analīzes. Patkovas et. al. pētījumā 46 % no pacientiem saņēma tikai antibiotisko terapiju, bet nevienam no pacientiem nebija smago komplikāciju, un tikai 17 % no tiem bija histoloģiski apstiprināts apendicīts. Prospektīvie un retrospektīvie pētījumi rāda tikai 97 % ārstēšanas efektivitāti nekomplicētos akūta apendicīta gadījumos bērniem. Neoperatīvā ārstēšana nekomplicētam akūtam pediatriskām apendicītam, pēc šim rezultātiem, ir droša. Mazāk pierādījumu ir par apendicīta ārstēšanu ar abscesu. Apendicītu ar appendikolītiem un perforēto apendicītu drošāk ārstēt ar apendektomiju.
Kā neoperatīvo ārstēšanu pediatrisko akūto apendicītu ārstēšana pielieto plaša spektra duālo antibiotisko terapiju intravenozi sākumā un orāli vēlākā stadijā. Biežākie varianti ir piperacillin-tazobactam intravenozi un ampicillin-clavulanate perorāli, vai meropenem-metronidazole intravenozi un ciprofloxacin-metronidazole perorāli, visi 7-10 dienu garumā.
Acute appendicitis is still the most common acute pediatric surgical disease, and a major cause of childhood morbidity and health care costs, mostly associated with complicated appendicitis. For a long time, appendicitis was treated solely by appendectomy, but nowadays antibiotic treatment has become popular based on its availability and effectiveness. There are theories, that uncomplicated appendicitis does not always lead to perforation. Unfortunately, the research evidence within pediatric field is still very limited compared to the adult disease. For that reason, clinics have developed their own clinical practice guidelines. The aim of this literature review is to gather the newest information about assessment and treatment of appendicitis in pediatric population, and to provide evidence for clinical decision making between non operative and operative management of appendicitis. Literature from online databases 2017 (2016) -2021 is reviewed and discussed. According to this literature review suggested variables for complicated appendicitis are >24/48h of symptoms, age <5 years, body temperature 38.0 or more, high leukocytosis, neutrophilia, hyponatremia and elevated procalcitonin. Variables suggesting uncomplicated disease are abdominal pain <48h, diameter of appendix maximum 1.1cm (imaging) and mild leukocytosis. The first randomized controlled trial pilot with at least five years follow-up about nonoperative treatment versus appendectomy for acute nonperforated appendicitis in children was by Patkova et al. (2020). Additionally, several retrospective or non-randomized studies have been conducted during these years, not to mention the meta-analyses. In Patkova study 46% of the patients receiving antibiotic treatment underwent appendectomy, but none of the patients had severe sequelae and only 17% of them had histologically confirmed appendicitis. Prospective and retrospective studies provide treatment efficacy up to 97% in uncomplicated acute appendicitis in children. Non operative management for uncomplicated acute pediatric appendicitis according to these results is safe. Less evidence is about management of acute appendicitis with abscess. According to the evidence appendicitis with appendicoliths and perforated appendicitis are safer to treat with appendectomy. As non-operative management in pediatric acute appendicitis broad spectrum, dual antibiotic treatment started with intravenous route and continued orally is a preferred option. Common options are piperacillin-tazobactam i.v. and ampicillin-clavulanate p.o. or meropenem-metronidazole i.v. and ciprofloxacin-metronidazole p.o. all in all for 7-10 days.
Acute appendicitis is still the most common acute pediatric surgical disease, and a major cause of childhood morbidity and health care costs, mostly associated with complicated appendicitis. For a long time, appendicitis was treated solely by appendectomy, but nowadays antibiotic treatment has become popular based on its availability and effectiveness. There are theories, that uncomplicated appendicitis does not always lead to perforation. Unfortunately, the research evidence within pediatric field is still very limited compared to the adult disease. For that reason, clinics have developed their own clinical practice guidelines. The aim of this literature review is to gather the newest information about assessment and treatment of appendicitis in pediatric population, and to provide evidence for clinical decision making between non operative and operative management of appendicitis. Literature from online databases 2017 (2016) -2021 is reviewed and discussed. According to this literature review suggested variables for complicated appendicitis are >24/48h of symptoms, age <5 years, body temperature 38.0 or more, high leukocytosis, neutrophilia, hyponatremia and elevated procalcitonin. Variables suggesting uncomplicated disease are abdominal pain <48h, diameter of appendix maximum 1.1cm (imaging) and mild leukocytosis. The first randomized controlled trial pilot with at least five years follow-up about nonoperative treatment versus appendectomy for acute nonperforated appendicitis in children was by Patkova et al. (2020). Additionally, several retrospective or non-randomized studies have been conducted during these years, not to mention the meta-analyses. In Patkova study 46% of the patients receiving antibiotic treatment underwent appendectomy, but none of the patients had severe sequelae and only 17% of them had histologically confirmed appendicitis. Prospective and retrospective studies provide treatment efficacy up to 97% in uncomplicated acute appendicitis in children. Non operative management for uncomplicated acute pediatric appendicitis according to these results is safe. Less evidence is about management of acute appendicitis with abscess. According to the evidence appendicitis with appendicoliths and perforated appendicitis are safer to treat with appendectomy. As non-operative management in pediatric acute appendicitis broad spectrum, dual antibiotic treatment started with intravenous route and continued orally is a preferred option. Common options are piperacillin-tazobactam i.v. and ampicillin-clavulanate p.o. or meropenem-metronidazole i.v. and ciprofloxacin-metronidazole p.o. all in all for 7-10 days.
Description
Medicīna
Medicine
Veselības aprūpe
Health Care
Medicine
Veselības aprūpe
Health Care
Keywords
pediatriskais apendicīts, neoperatīvā ārstēšana; antibiotiķi; apendektomija; komplicēts apendicīts; nekomplicēts apendicīts, pediatric appendicitis; non operative management; antibiotics; appendectomy; complicated appendicitis; uncomplicated appendicitis