Problematic issues of diagnosis and treatment of acute appendicitis in children

Abstract

Objective: to analyze the results of treatment of children with acute appendicitis and improve the algorithm of care.

Materials and methods. The study is based on the results of treatment of 269 children with acute appendicitis and its complications, who were treated in the period 2019-2020; the microbiological part of the work was analyzed on 2334 bacteriological cultures in patients with HA in the period 1997-2019; 239 pathohistological examinations of removed appendages in the period 2019-2020.

Results. The groups had different appendectomy techniques: 122 children underwent laparoscopic surgery, 147 children underwent laparotomy. In the group of children who underwent laparoscopic surgery in the structure of diagnoses: acute phlegmonous appendicitis – 51 (41.8%) children; primary peritonitis – 28 (22.9%) children; acute gangrenous-perforated appendicitis, abscess, purulent peritonitis – 24 (19.7%) children, acute gangrenous appendicitis – 16 (13.1%) children, catarrhal – 3 (2.5%) children. In 21 (17.2%) cases there was a conversion: the main reason for which was the lack of visualization of the tailbone, which led the surgeon to switch to laparotomy. Visualization of pathological changes during the ultrasound examination of the abdominal cavity occurred in 27 (31.4%) cases out of 86 performed. Intraoperative diagnosis and histopathological conclusion coincided in 65 (69%) cases. Of these: 74.5% with phlegmonous appendicitis; 68.5% with gangrenous appendicitis; 67% with gangrenous-perforated appendicitis, abscess, purulent peritonitis. In the group of children operated laparotomically in the structure of diagnoses: acute phlegmonous appendicitis – 60 (40.8%) children; acute gangrenous appendicitis – 66 (38%) children; gangrenous-perforative appendicitis, abscess, purulent peritonitis – 26 (17.7%) children. In 35 (44.3%) cases out of 79 in the preoperative ultrasound examination of the abdominal cavity, the tail was not visualized. Intraoperative diagnosis and histopathological conclusion coincided in 115 (78.2%) cases with 147. Comparing the results of treatment of both groups of children, it should be noted that in the group of children operated laparoscopically in 68.4% of cases during the ultrasound examination visualization of the tailbone was impossible. Due to the atypical location of the appendix in 17.2% of cases, which was not visualized during laparoscopy, conversion was performed. In the group of children operated laparotomically in 44.3% of cases, the tail, during the ultrasound examination, was not visualized due to the presence of destructive changes and complications in the abdominal cavity.

Conclusions. Diagnosis of acute appendicitis with an atypical location and the presence of anatomical abnormalities can be complicated and affect the choice of treatment, requires a full arsenal of diagnostic capabilities of the clinic. When performing laparoscopic surgery, it is necessary to control its duration, pressure in the abdominal cavity, to conduct visual inspection of the abdominal cavity, to determine the feasibility and timeliness of conversion, which ultimately affects the safety of the patient. According to our studies, in 43% of cases of examined children in the preoperative period, the appendix was not visualized sonographically, during diagnostic laparoscopy in 11.5% (according to our studies) failed to visualize the tailbone, which required the surgeon to convert. According to the research results, the sensitivity of the Alvarado scale was 89.8%, and the specificity was 75.9%, which indicates the expediency and necessity of using the scale when examining children with suspected acute appendicitis.