Częstość występowania powikłanej postaci ostrego zapalenia wyrostka robaczkowego – jednoośrodkowe badanie retrospektywne

Introduction

The first description of appendix appeared in 1521 by Da Carpi, who described it as an anatomical structure. However, it was not until the end of the nineteenth century that a more detailed description of the pathophysiology of appendicitis was presented [1, 2]. The awareness of its high mortality rate encouraged doctors to undertake active measures to develop methods for the management and treatment of the disease. Only in the twentieth century was a breakthrough in the treatment of acute appendicitis witnessed with the apparition of early diagnosis and subsequent appendectomy. The change of approach in the treatment of the disease led to improved results. The mortality rate began to fall: under 25% in 1915; about 5% in 1950; and currently < 0.01% in developed countries [3]. The reasons for this is earlier surgeries and the benefit of general anaesthesia, the improvement of surgical techniques and antibiotic therapy, the introduction of aseptic and antiseptic principles, and finally better haemostasis during surgeries [4, 5].
Nowadays, together with laboratory diagnostics and imaging, we are able to make an early diagnosis. This leads to the introduction of early adequate treatment and better outcomes [6–10].
The most widely used classification of the disease consists of uncomplicated and complicated forms of appendicitis. To clarify, the disease is defined as uncomplicated if the appendix has less advanced changes without perforation or diffuse peritonitis. This group is usually characterised by shorter hospital stay and fewer complications during treatment. In the case of complicated appendicitis, gangrenous with diffuse peritonitis, perforated appendix, or periappendicular abscess is observed. These clinical forms required longer hospitalisation, more expensive treatments, and more often result in severe post-operative complications [8].

Aim of the research

The main aim of the study is to analyse retrospectively the incidence, causes, and clinical course of complicated acute appendicitis.

Material and methods

A retrospective study included children aged 0–18 years, who were operated due to acute appendicitis between December 23, 2004 and July 11, 2016. Patients were treated in the Department of Paediatric Surgery, Urology, and Traumatology, Regional Hospital in Kielce, Poland. This study focused on demographic data, length of hospitalisation, antibiotic therapy, and intraoperative diagnosis.
Appendectomy was performed using either a laparoscopic or an open technique, depending on the preference of the surgeon. Higher prevalence of an open approach (58%) was noticed. All removed appendices were routinely submitted for histological evaluation.
In Poland, the most commonly used classification is by the nature of morphological changes in the appendix, which are assessed intraoperatively. Consequently, the following types of appendicitis are distinguished: simple surface, phlegmon and gangrenous appendicitis with possible perforation, and local or diffuse peritonitis.
In the study, as mentioned in the introduction, a grading system was applied to rate appendicitis between uncomplicated and complicated. According to the surgeon’s assessment, proper grading was established in each case.
In the case of acute appendicitis, the most common postoperative complications are wound infection and formation of intraperitoneal abscesses. Whereas long-term complications include mechanical obstruction and abscess formation. In the context of this research paper we do not focus on postoperative complications. Further studies will be necessary.

Results

A total of 2048 children who underwent appendectomy were included in the analysed period. Girls accounted for 36.9% while boys accounted for 63.1%. Children were classified into three age groups: the youngest (0–5), middle (6–10 years), and the oldest (11–18 years) (Table 1). The largest group comprised children under the age of 11 years. Their mean age was 10.7 years.
Diagnosis of appendicitis was based on symptoms, physical examination, blood tests, and imaging. The most common reported symptoms were abdominal pain and vomiting. In all children, routine ultrasound of the abdomen was performed by a radiologist together with white cell count and C-reactive protein (CRP) measurement. In uncertain cases ultrasound was repeated or computed tomography (CT) scan was performed (3 patients). The majority (69.4%) of patients were enrolled for surgery within 12 h of admission to the department. The delay in the rest of the cases was due to extended establishment of correct diagnosis, proper preparation of the patient, or availability of the operating theatre. During that time rehydration and antibiotic therapy were provided. Among those patients 18% had complicated appendicitis.
The average total length of stay was 8.3 days, with 65.3% of patients discharged within 7 days of their admission.
Most of the time children were administered two antibiotics (43.5% of cases). In contrast, one antibiotic was prescribed in 30.7% of cases, and three or more in 26.7%. The most commonly used antibiotics were Metronidazole and Cefuroxime.
Each conclusion of the surgeon’s report was studied, so that appendicitis cases were defined as uncomplicated or complicated. Furthermore, negative appendectomies in the studied period amounted to 0.5%, and no mortal cases were recorded.
The study analysed the incidence of complicated appendicitis over the years (Figures 1, 2). It was then divided into two time periods: 1) 2005–2007 and 2) 2008–2016. As can be seen in the second period under study, the incidence of acute appendicitis increased. Nonetheless the incidence of complicated appendicitis remained at a similar level. Consequently, the average rate of complicated acute appendicitis was 43.95%.
Figure 2 shows the occurrence of complicated acute appendicitis over the years in relation to all cases of acute appendicitis in the study. In first period the incidence of complicated acute appendicitis was around 59–61%, then it dropped to around 39–46% of all cases. In effect, a significant reduction in incidences after 2007 can be noticed.
The analysis of the age of the patients and the occurrence of the complicated appendicitis is shown in Figure 3. The frequency rate of complicated appendicitis was the highest for the youngest children, at 61%. Then middle children were at 46%, whereas older children were at 45%.

Discussion

Acute appendicitis is one of the most common causes of “acute abdomen”. Typically, it manifests with the classic triad of symptoms. It includes abdominal pain, nausea or vomiting, and increased body temperature. In addition to physical examination, ultrasound of the abdomen and blood tests are used to confirm diagnosis. This is particularly important for young and non-cooperating children. Ultrasonography is safe and readily available with high accuracy when used by an experienced radiologist. It is especially useful in children who are more sensitive to radiation. Consequently, it helps differentiate appendicitis from non-surgical reasons of abdominal symptoms [5–7]. In uncertain cases, abdominal CT might be performed.
Lately there have been reports on a satisfactory effect of non-operative management of acute appendicitis [11, 12] although the preferred treatment is still surgery combined with antibiotics [13]. In all cases the priority is to start the chosen treatment as soon as possible. It is known that there is a correlation between the time since the onset of symptoms and the risk factor for an event of complicated appendicitis [14]. However, that does not impact patients who are hospitalised and treated with intravenous hydration and antibiotics [15, 16].
In developed countries 15% to 30% of appendicitis cases are complicated [17, 18]. In contrast, among developing countries, that number rises to 60% with a mortality rate of 1%. Such high incidence is most of all due to insufficient access to medical professionals. There are also high costs of healthcare that must be borne by the patients, not to mention an inefficient system of health management. Other reasons exist. First of all, delays in the diagnostics due to the additional wait before seeking medical attention by patients and their caretakers, as well as the failure to diagnose appendicitis by the primary care physicians, and lastly the delayed referral to paediatric surgery departments [19–21].
In order to provide better access to health care in Poland, 24-hour Medical Service Units and Hospital Emergency Units were created. Thus, after 6.00 p.m. on weekdays and on Saturdays, Sundays, and holidays primary health services are provided by 24-hour Medical Service Units. In effect, patients can receive medical advice round the clock, closer to their homes. Whereas in Hospital Emergency Units, besides medical consultation, some diagnostic tools like ultrasonography, CT, or laboratory tests are available. As a result, we observed a decline in the incidence of complicated acute appendicitis after 2007 in our study [22, 23].
The duration of hospital stay was longer in patients with complicated appendicitis. This prolonged stay was usually due to the need for intravenous antibiotics, fluids, and pain medications or postoperative complications such as postoperative abscesses, wound infections, or mechanical obstruction. In otherwise healthy children after appendicitis we believe it is reasonable to aim for less than a 5-day post-operative stay.
The occurrence of complicated appendicitis is correlated with pre-hospital delay. A long duration of symptoms before admittance to surgical ward has higher risk of worse outcome. Among those children, we observed incidences of being hospitalised in paediatric departments and discharged or transferred with delay.
Furthermore, the incidence is also influenced by age. The youngest children have the highest risk of complicated acute appendicitis. Difficulty in communication, inadequate physical examination, and irritability may cause delay in the diagnosis and proper management. The non-specific clinical presentation in those children attributes to a high misdiagnosis rate [24].
Uncomplicated appendicitis requires less medications and is characterised by a shorter length of stay. There are also fewer postoperative complications. It is also important to consider that there is a much lower cost of treating patients with uncomplicated appendicitis compared to those with complicated appendicitis.
A study of Harbor-UCLA Medical Centre showed that a delay or failure to diagnose appendicitis in children is one of the most common reasons for lawsuits [25, 26].

Conclusions

There are still a lot of cases of complicated acute appendicitis. Increased awareness of parents, access to early diagnosis, and consultations with specialists are crucial. The cost to the healthcare system is substantial.

Conflict of interest

The authors declare no conflict of interest.

References

1. Hamill JK, Hill AG. A history of the treatment of appendicitis in children: lesson learned. ANZ J Surg 2016; 86: 762-767.
2. Williams GR. Presidential address: a history of appendicitis. With anecdotes illustrating its importance. Ann Surg 1983; 197: 495-506.
3. Turner GG. The mortality of appendicitis. Br Med J 1915; 1: 997-998.
4. McLanahan S. Further reductions in the mortality in acute appendicitis in children. Ann Surg 1950; 131: 853-864.
5. Gołębiowski A, Smyczek D, Kudela G, Janowicz T, Choiński W, Dymek K, Daniluk Matraś I, Grzechnik T, Wolak P. Postępowanie w ostrym zapaleniu wyrostka robaczkowego u dzieci. Ogólnopolskie badania ankietowe 2007-2011. Standardy Medyczne. Problemy Chirurgii Dziecięcej 2013; 3: 7-15.
6. Grata-Borkowska U. Bóle brzucha u dzieci – diagnostyka różnicowa i postępowanie terapeutyczne w POZ. Lekarz POZ 2016; 2: 151-155.
7. Caperell K, Pitetty P, Cros K. Race and acute abdominal pain in Pediatric Emergency Department. Pediatrics 2013; 131: 1098-1106.
8. Górecki W. Ostre zapalenie wyrostka robaczkowego. In: Chirurgia Dziecięca. PZWL, Warsaw 2016; 530-544.
9. Wolak P, Gołąbek T, Obarzanowski M, Chłosta P. A complex case of abdominal pain in a patient with pelviureteric junction obstruction. Videosurgery Miniinv 2014; 9: 273-275.
10. Adamczyk-Gruszka O, Gruszka J, Niziurski P. Acute appendicitis in a single and multiple pregnancy – a study of two cases. Studia Medyczne 2013; 29: 83-88.
11. Sakorafas GH, Mastoraki A, Lappas C, Sampanis D, Danias N, Smyrniotis V. Conservative treatment of acute appendicitis: heresy or an effective and acceptable alternative to surgery? Eur J Gastroenterol Hepatol 2011; 23: 121-127.
12. Fogg LK. Use of antibiotics alone for treatment of uncomplicated acute appendicitis: a systematic review and meta-analysis. Surgery 2011; 150: 673-683.
13. Ruffolo C, Fiorot A, Pagura G, Antoniutti M, Massani M, Caratozzolo E, Bonariol L, di Pinto FC, Bassi N. Acute appendicitis: what is the gold standard of treatment? World J Gastroenterol 2013; 19: 8799-8807.
14. Bickell NA, Aufses AH, Rojas M, Bodian C. How time affects the risk of rupture in appendicitis. J Am Coll Surg 2006; 202: 401-406.
15. Giraudo G, Baracchi F, Pellegrino L, Dal Corso HM, Borghi F. Prompt or delayed appendectomy? Influence of timing of surgery for acute appendicitis. Surg Today 2013; 43: 392-396.
16. Stahlfeld K, Hower J, Homitsky S, Madden J. Is acute appendicitis a surgical emergency? Am Surg 2007; 73: 626-629.
17. Johansen L, Thorup J, Rasmussen L. Prolonged length of stay and many readmissions after appendectomy. Dan Med Bul 2011; 58: A4296.
18. Lee SL, Stark R, Yaghoubian A, Shekherdimian S, Kaji A. Does age affect the outcomes and management of pediatric appendicitis? J Pediatr Surg 2011; 46: 2342-2345.
19. Kong VY, Sartorius B, Clarke DL. Acute appendicitis in the developing world is a morbid disease. Ann R Coll Surg Engl 2015; 97: 390-395.
20. Singh M, Kadian YS, Rattan KN, Jangra B. Complicated appendicitis: analysis of risk factors in children. Afr J Paediatric Surg 2014; 11: 109-113.
21. Głuszek S, Kot M. Posocznica w przebiegu zapalenia wyrostka robaczkowego – rozpoznawanie i leczenie. Wiad Lek 1988; 15: 991-996.
22. Journal of Laws 2004 No. 210, item 2135. ACT of August 27, 2004 on healthcare services financed from public funds.
23. Journal of Laws 2006 o. 191, item 1410. Act of September 8, 2006 on the National Medical Emergency Service.
24. Bech-Larsen S, Lalla M, Thorup J. The influence of age, duration of symptoms and duration of operation on outcome after appendicitis in children. Dan Med J 2013; 60: A4678.
25. Sullins V, Lee S. Malpractice in cases of pediatric appendicitis: a 30-year review. SoSU Committee Reports; October 11, 2014.
26. Asad S, Ahmed A, Ahmad S, Ali S, Ahmed S, Ghaffar S, Khattak IU. Causes of delayed presentation of acute appendicitis and its impact on morbidity and mortality. J Ayub Med Coll Abbottabad 2015; 27: 620-623.

Address for correspondence:

Aneta Piotrowska MD
Department of Paediatric Surgery, Urology and Traumatology
Regional Hospital
ul. Grunwaldzka 45, 25-736 Kielce, Poland
Phone: +48 41 303 33 23
E-mail: md.apiotrowska@gmail.com