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The Management of Post-appendectomy Abscess in Children; A Historical Cohort Study and Update of the Literature
Paul van Amstel1,2,3,4, Sarah-May M L The1,2,3,5, Irene M Mulder6
1Department of Pediatric Surgery, Emma Children's Hospital, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.
Insights
Conservative management of pediatric post-appendectomy abscess (PAA) is effective for small, unifocal abscesses. This study supports a standardized, non-invasive treatment protocol for specific PAA cases in children.
Area of Science:
- Pediatric Surgery
- Abdominal Imaging
- Infectious Diseases
Background:
- Post-appendectomy abscess (PAA) management in children lacks high-quality evidence, leading to varied clinical practices.
- Current treatment choices often reflect surgeon preference rather than evidence-based guidelines.
- There is a need for updated literature and robust data on PAA treatment outcomes in pediatric populations.
Purpose of the Study:
- To update the literature on pediatric PAA management.
- To evaluate treatment outcomes in a large, multicenter cohort of children with PAA.
- To compare the effectiveness of non-invasive versus invasive treatment strategies for PAA.
Main Methods:
- Comprehensive literature search of RCTs, cohort studies, and case series (2014 onwards) in PubMed and Embase.
- Retrospective multicenter cohort study of children (<18 years) with radiologically confirmed PAA (2014-2021).
- Comparison of non-invasive (antibiotics) and invasive (drainage) treatments, assessing treatment success defined by absence of further interventions.
Main Results:
- Literature review identified limited high-quality studies; treatment success rates varied (69-88% non-invasive, 56-100% invasive).
- Multicenter cohort included 70 children; 29 (41%) non-invasive, 41 (59%) invasive treatment.
- Non-invasive treatment success: 72% overall, 100% for small (<3 cm) unifocal PAA, 80% for medium (3-6 cm) unifocal PAA; ineffective for multiple abscesses.
Conclusions:
- Non-invasive treatment is safe and effective for unifocal, small to medium-sized (<6 cm) post-appendectomy abscesses in children.
- A standardized, step-up approach-based treatment protocol has been developed based on these findings.
- Prospective validation of the proposed treatment protocol is recommended to further refine pediatric PAA management.
Introduction:
Recent studies have shown that specific cases of post-appendectomy abscess (PAA) in children could be treated conservatively. However, due to the lack of high-quality evidence, choice of treatment still depends on preferences of the treating surgeon, leading to heterogeneity in clinical practice. Therefore, we aimed to provide an update of recent literature on the management of PAA in children and subsequently evaluate the outcomes of a large multicenter cohort of children treated for PAA.
Methods:
A literature search was performed in Pubmed and Embase, selecting all randomized controlled trials, prospective and retrospective cohort studies, and case series published from 2014 and onward and reporting on children (<18 years) treated for a PAA. Subsequently, a historical cohort study was performed, including all children (<18 years) treated for a radiologically confirmed PAA between 2014 and 2021 in a tertiary referral center and two large peripheral centers. Medical charts were reviewed to compare non-invasive (i.e., antibiotics) and invasive (i.e., drainage procedures) treatment strategies. Primary outcome was the success rate of treatment, defined as no need for further interventions related to PAA or its complications.
Results:
The search yielded 1,991 articles, of which three were included. Treatment success ranged between 69-88% and 56-100% for non-invasive and invasive strategies, respectively. Our multicenter cohort study included 70 children with a PAA, of which 29 (41%) were treated non-invasively and 41 (59%) invasively. In the non-invasive group, treatment was effective in 21 patients (72%) compared to 25 patients (61%) in the invasive group. Non-invasive treatment was effective in 100% of unifocal small (<3 cm) and 80% of unifocal medium size PAA (3-6 cm), but not effective for multiple abscesses.
Conclusion:
Non-invasive treatment of especially unifocal small and medium size (<6 cm) PAA in children seems to be safe and effective. Based on these results, a standardized treatment protocol was developed. Prospective validation of this step-up approach-based treatment protocol is recommended.
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