Appendectomy in Children and Adolescents

Appendicitis is the most common reason for surgical treatment in children and adolescents (1). Up until 2000, the international consensus was to surgically remove any acutely inflamed appendix as quickly as possible. This was based on the view that progression of inflammation inevitably results in perforation (2). Older epidemiological studies found that the lifetime risk of developing appendicitis was 6.7% in women and 8.6% in men. Surprisingly, in women 23.1% of cases underwent appendectomy, but only 12% in men. One of the reasons for this disparity was that girls and young women with acute abdominal pain were very often advised to have their appendix surgically removed for “safety reasons”. When laparoscopy was introduced, simultaneous appendectomy was frequently performed unnecessarily—even with negative intraoperative findings—“to be on the safe side“ (3).

Evaluation of different surgical techniques

Many studies mention that among children up to the age of 5, “acute appendicitis“ is in 50% of cases only diagnosed after perforation (2). This is where the study by Rolle et al. comes in and looks at the question under which circumstances an open surgical or minimally invasive procedure is indicated (4). To this end, the authors analyzed health insurance data and arrived at the conclusion that, up to the age of 5, both surgical techniques achieve equal outcomes. It is only from adolescence onwards that patients clearly benefit from a minimally invasive approach. Furthermore, extensive experience on the part of the treating surgeons reduces the risk of potential complications in patients with complicated appendicitis (4).

On the basis of health insurance registry data, however, such important statements can only be made with some reservations. The extent of inflammation, especially peritonitis and abscess formation, and the histological findings cannot be extracted from health insurance data. For this reason, particular caution should be exercised when interpreting these data. The question of “negative appendectomies“—i.e., removal of a non-inflamed appendix—remains unanswered. Consequently, there is a need to conduct further randomized multicenter trials in the future to provide answers to these important questions, especially to differentiate between acute uncomplicated appendicitis and acute complicated appendicitis with peritonitis/abscess formation. The timing of appendectomy (immediately as an emergency or on the next day), the role of conservative treatment and the choice of antibiotic therapy also remain uncertain up until now (5, 1).

Diagnosis more challenging in children

Especially in infants and toddlers, it is difficult to diagnose acute appendicitis (1). Unlike in adults, the slender greater omentum (omentum majus) in young children cannot cover a perforation. But while today a fatal outcome of complicated appendicitis with peritonitis is rare, the treatment of the condition is still challenging.

In Germany, only one S1 guideline existed; an S2k guideline was planned to be issued by 31 December 2023. The clinical assessment by an experienced surgeon is of great importance and essential for diagnosis. Over decades, the motto has been „when in doubt, perform surgery“. However, already in 2001, a “negative appendectomy” was found in 12% of cases (6). The Dutch 2010 and 2019 S3 clinical practice guidelines showed a “negative appendectomy” in up to 16 % of cases (7). Furthermore, among these 16% (especially girls aged > 13 years), surgical site infections, abdominal abscesses and adhesions were observed; for this reason, the “negative appendectomy” was considered a complication (7).

So, it is not easy to diagnose an “acute appendicitis”, it requires substantial experience. Collectively, the clinical, laboratory and radiographic findings lead to the correct diagnosis. In a 2017 meta-analysis, pain migration from the periumbilical area to the right lower quadrant in combination with hop pain showed the best correlation with acute appendicitis. Concomitant symptoms included nausea, loss of appetite and increased body temperature (8). While the use of scores is helpful in adults, it does not offer any noticeable advantage in children (9).

Medical imaging techniques, such as ultrasonography and magnetic resonance imaging (MRI), are indispensable for diagnosis (5). While favored in North America, computed tomography (CT) is used with great caution in Europe owing to the associated radiation exposure (5). Even though ultrasonography alone is inferior to CT, its diagnostic value in combination with clinical and laboratory finding is similar. In unclear cases, ultrasonography should be repeated or an MRI should be obtained (6).

Abdominal versus pediatric surgery

Up until the early 1990s, appendectomy was almost exclusively performed using an open surgical approach. From the mid-1990s, the laparoscopic procedure made its way into the treatment of adult patients, and later, more hesitantly, also into pediatric surgery. Initially, reports focused on the feasibility of the laparoscopic approach, later on its superiority, despite the lack of relevant randomized controlled trials. Based on health insurance data, it was initially postulated that abdominal surgeons achieved better outcomes compared to pediatric surgeons (10). The study design, however, did not allow to draw this conclusion, since data on important characteristics were not collected. For example, no data on the severity of the inflammation, the extent of peritonitis present, primary abscess formation, and the number of negative appendectomies were available.

Non-surgical treatment

Over the past 15 years, non-surgical treatment has gained in importance. It has been successfully used as a final treatment for uncomplicated appendicitis. In less than 20% of cases, there is a need for appendectomy due to recurrence later in the clinical course (3). Furthermore, antibiotic therapy has successfully been used in patients with complicated appendicitis, at times in combination with ultrasound-guided drainage, to allow final minimally invasive surgical treatment after the acute inflammation has subsided; this strategy is associated with less complications (8, 5, 1).

Conclusion

There are still many unanswered questions with regard to appendicitis that need to be addressed in future studies.