Long-Term Outcome of Nonoperative Treatment of Appendicitis.

This cohort study uses registry data to report the long-term outcomes of patients who participated in randomized clinical trials of antibiotics vs surgery in Sweden in the 1990s.

Anal Fissure in Children.

Anal fissure is a common clinical problem in children and is defined as a longitudinal tear in the anal canal. The typical presentation is painful defecation and rectal bleeding. The etiology of anal fissure is unknown, but passage of hard stools and increased internal anal sphincter pressure are considered important factors. The treatment is oriented to relieve the spasm of the internal anal sphincter, which prevents healing of the fissure. Conservative management with stool softeners, topical analgesics, and sitz baths is recommended as first-choice therapy. Surgical treatment has been replaced by nonoperative management as definitive therapy, which is associated with a marginally higher success rate than placebo. Most recent studies have focused on nonoperative treatment with glyceryl trinitrate, calcium channel blockers, or botulinum toxin injection treatment. There are a few controlled studies to compare the different nonoperative treatment options in children. Success rates vary between the studies, and there is no clear evidence about which is the optimal nonoperative treatment. A significant recurrence rate has been reported after nonoperative management of anal fissure. It is important to treat constipation to avoid recurrent tears in the anal canal.

Nonoperative Treatment Versus Appendectomy for Acute Nonperforated Appendicitis in Children: Five-year Follow Up of a Randomized Controlled Pilot Trial.

OBJECTIVE: The aim of this study was to evaluate the safety and feasibility of nonoperative treatment of acute nonperforated appendicitis in children during 5 years of follow-up. METHODS: A 4-year follow-up of a previous randomized controlled pilot trial, including 50 children with acute nonperforated appendicitis, was performed. The patients were initially randomized to nonoperative treatment with antibiotics or appendectomy with 1-year follow-up previously reported. Data were extracted from the computerized notes and telephone interviews.The primary outcome was treatment failure, defined as need for a secondary intervention under general anesthesia, related to the previous diagnosis of acute nonperforated appendicitis. RESULTS: The children were followed up for at least 5 years [median 5.3 (range 5.0-5.6)] after inclusion. There were no failures in the appendectomy group (0/26) and 11 failures in the nonoperative group (11/24). Nine failures had occurred during the first year after inclusion, 2 of whom had histologically confirmed appendicitis. There were 2 further patients with recurrent acute appendicitis 1 to 5 years after inclusion. Both these patients had uncomplicated laparoscopic appendectomies for histologically confirmed acute appendicitis. There were no losses to follow-up. CONCLUSIONS: At 5 years of follow-up 46% of children treated with antibiotics for acute nonperforated appendicitis had undergone an appendectomy, although acute appendicitis was only histologically confirmed in 4/24 (17%). Treatment with antibiotics seems to be safe in the intermediate-term; none of the children previously treated nonoperatively re-presented with complicated appendicitis.

In-hospital Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children: A Single-center Retrospective Cohort Study.

OBJECTIVE: To investigate the correlation between in-hospital surgical delay before appendectomy for suspected appendicitis and the finding of perforated appendicitis in children. METHODS: All children undergoing acute appendectomy for suspected acute appendicitis at Karolinska University Hospital, Stockholm, Sweden from 2006 to 2013 were reviewed for the exposure of surgical delay. Primary endpoint was the histopathologic finding of perforated appendicitis. The main explanatory variable was in-hospital surgical delay, using surgery within 12 hours as reference. Secondary endpoints were postoperative wound infection, intra-abdominal abscess, reoperation, length of hospital stay, and readmission. To adjust for selection bias, a logistic regression model was created to estimate odds ratios for the main outcome measures. Missing data were replaced using multiple imputation. RESULTS: The study comprised 2756 children operated for acute appendicitis. Six hundred sixty-one (24.0%) had a histopathologic diagnosis of perforated appendicitis. In the multivariate logistic regression analysis, increased time to surgery was not associated with increased risk of histopathologic perforation. There was no association between the timing of surgery and postoperative wound infection, intra-abdominal abscess, reoperation, or readmission. CONCLUSIONS: In-hospital delay of acute appendectomy in children was not associated with an increased rate of histopathologic perforation. Timing of surgery was not an independent risk factor for postoperative complications. The results were not dependent on the magnitude of the surgical delay. The findings are analogous with previous findings in adults and may aid the utilization of available hospital- and operative resources.

Outcome after introduction of laparoscopic appendectomy in children: A cohort study.

INTRODUCTION: Acute appendicitis in children is common and the optimal treatment modality is still debated, even if recent data suggest that laparoscopic surgery may result in shorter postoperative length of stay without an increased number of complications. The aim of the study was to compare the outcome of open and laparoscopic appendectomies during a transition period. MATERIALS AND METHODS: This was a retrospective cohort study with prospectively collected data. All patients who underwent an operation for suspected appendicitis at the Astrid Lindgren Children's Hospital in Stockholm between 2006 and 2010 were included in the study. RESULTS: 1745 children were included in this study, of whom 1010 had a laparoscopic intervention. There were no significant differences in the rate of postoperative abscesses, wound infections, readmissions or reoperations between the two groups. The median operating time was longer for laparoscopic appendectomy than for open appendectomy, 51 vs. 37minutes (p<0.05). The postoperative length of stay was similar in the two groups. A simple comparison between the groups suggested that laparoscopic appendectomy had a shorter median postoperative length of stay, 43 vs. 57hours (p<0.05). However, there was a trend in time for a shorter postoperative length of stay, and a trend for more of the procedures to be performed laparoscopically over time so on regression analysis, the apparent decrease in length of stay with laparoscopy could be ascribed to the general trend toward decreased length of stay over time, with no specific additional effect of laparoscopy. CONCLUSIONS: Our data show no difference in outcome between open and laparoscopic surgery for acute appendicitis in children in regard of complications. The initial assumption that the patients treated with laparoscopic surgery had a shorter postoperative stay was not confirmed with linear regression, which showed that the assumed difference was due only to a trend toward shorter postoperative length of stay over time, regardless of the surgical intervention.

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.