RESUMEN
Introducción: La apendicitis aguda (AA) es la patología quirúrgicamás frecuente en Pediatría. Las publicaciones sobre la antibioterapia másadecuada como profilaxis y tratamiento de la AA en niños son limitadas. Material y métodos: Se realizó un análisis retrospectivo en pacien-tes menores de 14 años hospitalizados con AA. Se comparó el períodoprevio a la implantación del programa de optimización del uso de losantimicrobianos (PROA), pre-PROA (septiembre 2017-marzo 2019) yposterior, post-PROA (abril 2019-septiembre 2019). Resultados:Se incluyeron 206 pacientes: 139 del período pre-PROA y 67 post-PROA. Destacamos la mayor utilización de biterapia(ceftriaxona y metronidazol) y monoterapia (cefoxitina) en el períodopost-PROA (p= 0,0001), con ucción del uso de amoxicilina-clavu-lánico y piperacilina-tazobactam como terapia empírica (p= 0,0001).Para determinar el paso a terapia oral, se estableció el cumplimentode criterios clínicos (estado afebril, tránsito mantenido, tolerancia oraladecuada y con buen control del dolor vía oral) y analíticos (descensode la PCR al menos un 20-50% del valor máximo y leucocitos ≤ 12.000/mm3). Esto permitió un incremento de la secuenciación del tratamientooral en el período post-PROA (p= 0,03). No hubo diferencias en laestancia hospitalaria ni complicaciones entre ambos períodos, aunquese emplearon antimicrobianos de menor espectro con terapia oral deforma más precoz en la etapa post-PROA. Conclusiones: Es recomendable la implementación del PROA enpatologías quirúrgicas y elaborar protocolos adaptados al perfil micro-biológico y resistencias de cada unidad.(AU)
Introduction: Acute appendicitis (AA) is the most frequent surgi-cal pathology in pediatrics. However, publications discussing the mostadequate antibiotic therapy for AA prophylaxis and treatment in childrenare limited. Materials and methods: A retrospective analysis of patients under14 years of age hospitalized as a result of AA was carried out. Theperiods pre- and post- implementation of an antimicrobial optimizationprogram (AOPR) were compared. The pre-AOPR period went fromSeptember 2017 to March 2019, while the post-AOPR period went fromApril 2019 to September 2019. Results: 206 patients were included, 139 in the pre-AOPR group,and 67 in the post-AOPR group. Dual therapy (ceftriaxone + metro-nidazole) and single therapy (cefoxitin) were more commonly usedin the post-AOPR group (p= 0.0001), with reduced use of amoxicil-lin + clavulanic acid and piperacillin + tazobactam as an empiricaltherapy (p= 0.0001). To determine whether conversion to oral therapywas feasible or not, a number of clinical (no fever, sustained transit,adequate tolerance with satisfactory oral pain control) and blood test(a 20-50% CRP decrease from its highest level and a ≤ 12,000/mm 3leukocyte count) criteria were established. This allowed conversion tooral treatment to increase in the post-AOPR period (p=0.03). No dif-ferences in terms of hospital stay or complications were found betweenperiods, but narrower spectrum oral antimicrobials were used earlierin the post-AOPR period. Conclusions: Implementing an AOPR for surgical pathologies andestablishing protocols adapted to the resistance and microbiologicalprofile found at each unit is strongly recommended.(AU)
Asunto(s)
Humanos , Masculino , Femenino , Niño , Adolescente , Apendicitis , Programas de Optimización del Uso de los Antimicrobianos , Resistencia a Medicamentos , Profilaxis Antibiótica , Pediatría , Cirugía General , Estudios RetrospectivosRESUMEN
INTRODUCCIÓN: Las apendicitis atípicas corresponden aproximadamente a un 39.2% de todos los casos de apendicitis. La apendicitis de ubicación típica inicia con un dolor agudo alrededor del ombligo que posteriormente migrará a la fosa ilíaca derecha; sin embargo, la condición de cada paciente debe ser orientada en detalles que surgen de una minuciosa anamnesis, contemplando los antecedentes del paciente y el desarrollo de la sintomatología. CASO CLÍNICO: Paciente masculino de 17 años, con antecedente de hepatectomía derecha hace 15 años. Acude con por dolor abdominal continuo de cinco días de evolución localizado en hipocondrio derecho, náusea, vómito y fiebre. En exámenes complementarios se evidenció: leucocitosis, neutrofilia, procalcitonina y PCR ambas elevadas. Tomografía fue sugerente de proceso inflamatorio en región torácica derecha baja e hipocondrio derecho. Se realizó una laparoscopía diagnóstica con conversión a laparotomía exploratoria; evidenciando líquido purulento en corredera parietocólica derecha, adherencias, plastrón apendicular en región sub y retro hepática derecha formado por ciego, íleon distal, epiplón y apéndice. Se realizó apendicetomía, lavado de cavidad y colocación de drenaje. EVOLUCIÓN: En el post-quirúrgico el paciente tuvo mala evolución clínica, con neumonía asociada a los cuidados de la salud, además con necesidad de una segunda intervención quirúrgica por formación de colección sub-hepática. Luego de 13 días de cuidados hospitalarios, luego de la segunda intervención quirúrgica, presentó adecuada recuperación y fue dado de alta médica. CONCLUSIÓN: El médico debe poseer una alta sospecha clínica de apendicitis de ubicación atípica ante cuadros de abdomen agudo; ya que cuando estos casos son subdiagnosticados se incrementa el riesgo de complicaciones, con perforación y peritonitis y con estancia hospitalaria prolongada. El tratamiento de primera elección frente a una apendicitis complicada es la intervención quirúrgica.
BACKGROUND: Atypical appendicitis corresponds to approximately 39.3% of all appendicitis cases. Typically located appendicitis begins with acute pain around the belly button, which will later migrate to the right iliac fossa; however, the patient's condition must be oriented in details that arise from a meticulous anamnesis, considering the patients history and the development of the symptoms. CASE REPORTS: 17-year-old male patient with history of right hepatectomy 15 years ago. He presented with five day evolution continuous abdominal pain, located in the right upper quadrant, nausea, vomiting and fever. Complementary laboratory tests evidenced: leukocytosis, neutrophilia, elevated procalcitonin and CRP. Tomography was suggestive of an inflammatory process in the lower right thoracic region and the right upper quadrant. A diagnostic laparoscopy was performed, it was converted into an exploratory laparotomy, showing purulent fluid in the right parietocolic gutter, adhesions, appendicular plastron in the right sub and retrohepatic region formed by the cecum, distal ileum, omentum and appendix. Retrohepatic appendix with perforation in the middle third, appendicular base and poor quality cecum. An appendectomy, cavity lavage was performed, with placement of a drain. EVOLUTION: During the postoperative period, the patient had a poor clinical evolution, with health care associated pneumonia, in addition to the need for a second surgical intervention due to the formation of a sub-hepatic collection. After 13 days of hospital care, after the second surgical intervention, he presented an adequate recovery and was discharged from the hospital. CONCLUSION: Physicians must have a high clinical suspicion of atypical location appendicitis in the presence of acute abdomen; since a late diagnosis of this cases increases the risk of complications, with perforation and peritonitis and prolonged hospital stay. The first-line treatment for complicated appendicitis is surgical intervention.
Asunto(s)
Humanos , Masculino , Adolescente , Apendicitis/diagnóstico , Peritonitis , Perforación Intestinal , Laparotomía/métodos , Diagnóstico Diferencial , Complicaciones IntraoperatoriasRESUMEN
Objective To study the effect and safety of endoscopic retrograde appendicitis therapy (ERAT) in treating patients with uncomplicated acute appendicitis. Methods Patients with uncomplicated acute appendicitis were enrolled and divided into ERAT group and LA group received laparoscopic appendectomy. Then compare treat-ment condition, complications and follow-up of the two groups. Results ERAT were completed successfully in all the patients in ERAT group, while one patient underwent a reversion to open appendectomy for technical difficulties in LA group. Mean operative time was (49.7 ± 18.2) min for ERAT group and (68.9 ± 25.9) min for LA group (P <0.05). Fever relief time (1.3 ± 0.5) d, WBC normalization time (2.0 ± 0.9) d, mean bed time (0.1 ± 0.2) d and mean hospital stay (3.3 ± 1.6) d for ERAT group were significantly lower than LA group (P <0.05). 14 patients with intra-luminal appendicoliths (7 of massive appendicoliths, 4 of broken appendicoliths and 3 of broken appendicoliths with luminal stenosis) underwent endoscopic lithotomy successfully in ERAT group, resulting in a success rate of 100.00%. One patient presented perforation after ERAT was cured with conservative treatment. During the follow-up of at least 1/2 year, the rate of recurrence was 10.00% in ERAT group. 1 patient (5.00%) underwent LA at the 5th month after ERAT during the follow-up. Conclusion ERAT is an effective and safe therapy in treating patients with uncomplicated acute appendicitis with advantages of minimal invasiveness and quick recovery. Uncomplicated acute appendicitis with appendicoliths and/or luminal stenosis are the most suitable indications for ERAT.
