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Influencia de la pandemia por coronavirus 2(sars-cov-2) en la apendicitis aguda. Sars-cov-2 en la apendicitis aguda

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Resumen Introducción: La apendicitis aguda (AA) es la urgencia quirúrgica abdominal más frecuente. No encontramos estudios específicos que evalúen el impacto de la pandemia causada por el coronavirus 2 (SARS-Cov-2) sobre la AA y su tratamiento quirúrgico. Analizamos la influencia de esta nueva patología sobre la AA. Material y métodos: Estudio observacional retrospectivo en pacientes intervenidos por AA desde enero hasta abril de 2020. Fueron clasificados según el momento de la apendicectomía, antes de la declaración del estado de alarma (Pre-COVID19) y después de la declaración del estado de alarma (Post-COVID19) en España. Se evaluaron variables demográficas, duración de la sintomatología, tipo de apendicitis, tiempo quirúrgico, estancia hospitalaria y complicaciones postoperatorias. Resultados: Se incluyeron 66 pacientes (41 Pre-COVID19; 25 Post-COVID19 con edad media de 10.7±3 y 9.3±3.1; p=0.073; respectivamente). La fiebre se encontró en un mayor número de pacientes post-COVID19 (52 vs 19.5%; p=0.013), así como una PCR más elevada (72.7±96.2 vs 31.3±36.2 mg/dl; p=0.042). Este grupo presentó una mayor proporción de apendicitis complicada al compararle con el Pre-COVID19 (32 vs 7.3%; p= 0.015). La estancia media hospitalaria fue mayor en el grupo Post-COVID19 (5.6±5.9 vs 3.3±4.3 días; p=0.041). No se encontraron diferencias en el tiempo de evolución de los síntomas ni en el tiempo quirúrgico. Conclusiones: La pandemia por SARS-Cov-2 influye en el momento de diagnóstico de la apendicitis, así como en su grado de evolución y estancia hospitalaria. La peritonitis fue lo más frecuentemente observado. Una sospecha y orientación clínica más temprana, es necesaria para evitar un manejo inadecuado de este trastorno quirúrgico común.
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Influencia de la pandemia por coronavirus 2(sars-cov-2) en la apendicitis
aguda. Sars-cov-2 en la apendicitis aguda
Mar´
ıa Velayos Antonio Jes´
us Mu˜
noz-Serrano Karla
Estefan´
ıa-Fern´
andez MaCarmen Sarmiento Caldas Lucas Moratilla
Lape˜
na Manuel L´
opez-Santamar´
ıa Juan Carlos L´
opez-Guti´
errez
PII: S1695-4033(20)30179-X
DOI: https://doi.org/doi:10.1016/j.anpedi.2020.04.022
Reference: ANPEDI 2857
To appear in: Anales de Pediatria
Received Date: 23 April 2020
Accepted Date: 30 April 2020
Please cite this article as: Velayos M, Mu˜
noz-Serrano AJ, Estefan´
ıa-Fern´
andez K, Carmen
Sarmiento Caldas M, Lape ˜
na LM, L´
opez-Santamar´
ıa M, L´
opez-Guti´
errez JC, Influencia de la
pandemia por coronavirus 2(sars-cov-2) en la apendicitis aguda. Sars-cov-2 en la apendicitis
aguda, Anales de Pediatria (2020), doi: https://doi.org/10.1016/j.anpedi.2020.04.022
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ANPEDIA-20-273
INFLUENCIA DE LA PANDEMIA POR CORONAVIRUS 2(SARS-COV-2) EN
LA APENDICITIS AGUDA. SARS-COV-2 EN LA APENDICITIS AGUDA
Título abreviado: SARS-Cov-2 en la apendicitis aguda.
María Velayos*, Antonio Jesús Muñoz-Serrano, Karla Estefanía-Fernández, Mª Carmen
Sarmiento Caldas, Lucas Moratilla Lapeña, Manuel López-Santamaría, Juan Carlos
López-Gutiérrez.
Servicio de Cirugía Pediátrica. Hospital Universitario La Paz. Madrid.
*Correo electrónico: mariavelayos@icloud.com.
Introducción. La apendicitis aguda (AA) es la urgencia quirúrgica abdominal más
frecuente. No encontramos estudios específicos que evalúen el impacto de la pandemia
causada por el coronavirus 2 (SARS-Cov-2) sobre la AA y su tratamiento quirúrgico.
Analizamos la influencia de esta nueva patología sobre la AA.
Material y métodos. Estudio observacional retrospectivo en pacientes intervenidos por
AA desde enero hasta abril de 2020. Fueron clasificados según el momento de la
apendicectomía, antes de la declaración del estado de alarma (Pre-COVID19) y después
de la declaración del estado de alarma (Post-COVID19) en España. Se evaluaron
variables demográficas, duración de la sintomatología, tipo de apendicitis, tiempo
quirúrgico, estancia hospitalaria y complicaciones postoperatorias.
Resultados. Se incluyeron 66 pacientes (41 Pre-COVID19; 25 Post-COVID19 con edad media
de 10.73 y 9.33.1; p=0.073; respectivamente). La fiebre se encontró en un mayor número de
pacientes post-COVID19 (52 vs 19.5%; p=0.013), así como una PCR más elevada (72.7±96.2 vs
31.3±36.2 mg/dl; p=0.042). Este grupo presentó una mayor proporción de apendicitis complicada
al compararle con el Pre-COVID19 (32 vs 7.3%; p= 0.015). La estancia media hospitalaria fue
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mayor en el grupo Post-COVID19 (5.6±5.9 vs 3.3±4.3 días; p=0.041). No se encontraron
diferencias en el tiempo de evolución de los síntomas ni en el tiempo quirúrgico.
Conclusiones. La pandemia por SARS-Cov-2 influye en el momento de diagnóstico de
la apendicitis, así como en su grado de evolución y estancia hospitalaria. La peritonitis
fue lo más frecuentemente observado. Una sospecha y orientación clínica más temprana,
es necesaria para evitar un manejo inadecuado de este trastorno quirúrgico común.
Palabras clave: Apendicitis aguda; Apendicectomía; SARS-Cov-2; Paciente pediátrico;
Complicaciones postquirúrgicas.
INFLUENCE OF THE CORONAVIRUS 2 (SARS-COV-2) PANDEMIC ON
ACUTE APPENDICITIS
SARS-COV-2 IN ACUTE APPENDICITIS
Introduction. Acute appendicitis (AA) is the most common abdominal surgical emergency. No
specific studies have been found that evaluate the impact of the coronavirus 2 (SARS-Cov-2)
pandemic on AA and its surgical management. An analysis was made on the influence of this
new pathology on the clinical course of AA.
Material and methods. Retrospective observational study was conducted on patients operated
on for AA from January to April 2020. They were classified according to the time of the
appendectomy, before the declaration of the state of alarm (Pre-COVID-19), and after its
declaration (Post-COVID-19) in Spain, one the most affected countries in the world. An
evaluation was made of demographic variables, duration of symptoms, type of appendicitis,
surgical time, hospital stay, and postoperative complications.
Results. The study included 66 patients (41 Pre-COVID-19; 25 Post-COVID-19) with mean age
of 10.7±3 and 9.3±3.1; P=.073, respectively. Fever was found in a higher number of post-COVID-
19 patients (52 vs 19.5%; P=.013), as well as a higher CRP (72.7±96.2 vs 31.3±36.2 mg/dL;
P=.042). This group presented with a higher proportion of complicated appendicitis when
compared to Pre-COVID-19 (32 vs 7.3%; P=.015). The mean hospital stay was longer in the Post-
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COVID-19 group (5.6±5.9 vs 3.2±4.3 days; P=.041). No differences were found in the time of
onset of symptoms or surgical time.
Conclusions. The SARS-Cov-2 pandemic influenced the time of diagnosis of appendicitis, as
well as its course, and mean hospital stay. Peritonitis was more frequently seen. As a result of the
significant circumstances, delaying diagnosis and treatment of AA during SARS-Cov-2
pandemic, inappropriate management of this common surgical disorder has been noticed.
Keywords: Acute appendicitis; Appendectomy; SARS-Cov-2; Paediatric patient; Post-surgical
complications.
Introducción
La apendicitis aguda (AA) es la urgencia quirúrgica más frecuente en la población pediátrica(1,2).
De los niños que acuden a Urgencias por dolor abdominal agudo, entre el 1-8% son
diagnosticados de apendicitis aguda(3). El retraso en el diagnóstico y la instauración del
tratamiento están relacionados con las formas más evolucionadas de AA(4,5).
El diagnóstico y tratamiento precoz son las mejores armas para reducir la tasa de complicaciones.
Diferentes scores han sido diseñados para estimar el riesgo de apendicitis como la The apendicitis
Inflamatory Response (AIR) o la puntuación Alvarado, siempre utilizándose de manera
complementaria y nunca como dato confirmatorio del diagnóstico(6,7).
Ante la confirmación de AA el tratamiento más extendido entre los cirujanos pediátricos es la
apendicectomía, abierta o laparoscópica. No obstante, en los últimos años, varias investigaciones
sobre el tratamiento conservador con antibioterapia de la apendicitis aguda no complicada han
sido desarrollados con resultados prometedores pero aún no concluyentes que deben ser
interpretados con cautela(8,9).
La pandemia desatada por el coronavirus 2(SARS-Cov-2) cuya principal dolencia es un ndrome
respiratorio agudo, ha hecho que todas las patologías previas a la misma, incluida la apendicitis
aguda, convivan con esta nueva situación a diario en los centros sanitarios(10). No se han
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encontrado estudios en la bibliografía publicada hasta ahora, que analicen el impacto de la misma
en la apendicitis aguda y en su tratamiento quirúrgico.
El objetivo de este estudio fue analizar la influencia de la pandemia por coronavirus 2(SARS-
Cov-2) sobre el tiempo transcurrido desde el inicio de los síntomas hasta el diagnóstico de AA,
así como el efecto que esto conlleva sobre el grado de evolución de la misma, procedimiento
quirúrgico, estancia hospitalaria y complicaciones postoperatorias en pacientes pediátricos.
Material y Métodos
Diseño del estudio
Realizamos un estudio observacional retrospectivo sobre pacientes pediátricos con diagnóstico
de AA en nuestro centro desde enero hasta abril de 2020.
Los pacientes fueron clasificados en dos grupos según la fecha en la que se declaró el estado de
alarma en España por pandemia de SARS-Cov-2(Real Decreto 463/2020 del 14 de marzo de
2020): intervenidos antes de la declaración del estado de alarma (Pre-COVID19) e intervenidos
después de la declaración del estado de alarma (Post-COVID19).
Se incluyeron todos los pacientes intervenidos de apendicectomía (abierta o laparoscópica)
menores de 18 años, diagnosticados en nuestro centro o trasladados de otros centros con sospecha
de apendicitis o apendicitis aguda ya confirmada, tras obtener el consentimiento escrito por padres
o tutores legales. Se excluyeron aquellos pacientes en los que se decidió no realizar cirugía y
tratar de forma conservadora, aquellos cuyos padres o tutores legales no aceptaron la cirugía como
tratamiento y en los que no se pudieron obtener los datos necesarios para las variables estudiadas.
La intervención quirúrgica llevada a cabo no fue diferente a la técnica habitual y fue la misma
para ambos grupos.
Datos
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Los datos epidemiológicos, clínicos, resultados de test sanguíneos, microbiológicos y
pruebas radiológicas se obtuvieron del Sistema de Registro Médico Electrónico de
nuestro centro.
Se recogieron variables demográficas, clínicas, del procedimiento quirúrgico y de la
evolución.
Análisis estadístico
Los datos fueron recogidos usando Microsoft Excel, versión 16.35 y las variables
descritas fueron analizadas mediante el uso del paquete estadístico IBM SPSS Statistics
25.0. Las variables categóricas fueron descritas con frecuencias y porcentajes, y las
continuas como media y desviación estándar. Para comprobar la distribución de las
variables, normal o no, se llevó a cabo la prueba de Kolmogorov-Smirnoff (corregida por
Lillifors). Se compararon las variables categóricas con el test de la Chi-cuadrado o el test
exacto de Fisher y las variables cuantitativas con el test de la T de Student (en variables
con distribución normal) y el test de la U de Mann-Whitney (en variables que no seguían
una distribución normal). El valor p<0,05 fue considerado estadísticamente significativo
y todos los intervalos fueron calculados con una confianza del 95%.
Resultados
Un total de 66 pacientes fueron intervenidos por AA en nuestro centro desde enero hasta abril de
2020. Cuarenta y uno en el grupo intervenido antes de la declaración del estado de alarma (Pre-
COVID19) y 25 en el grupo intervenido después de la declaración del estado de alarma (Post-
COVID19). Un paciente, en el que se decidió tratamiento conservador y apendicectomía diferida,
fue excluido. Figura 1.
En primer lugar, se llevo a cabo un estudio descriptivo de las principales variables de interés en
ambos grupos que se muestra en la Tabla 1 y 2.
Tiempo de evolución de los síntomas.
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Se observó un tiempo más largo en los pacientes Post-COVID19 que en los pacientes Pre-
COVID19, sin encontrarse diferencias estadísticamente significativas (46.1±43.8 horas vs
30.2±30.5 horas respectivamente; p=0.346). Una mayor proporción de pacientes presentaron
fiebre en el grupo Post-COVID19 frente al grupo Pre-COVID19, diferencias estadísticamente
significativas (52% vs 19.5% respectivamente; p=0.013). Lo mismo se observó en relación con
la Proteína C Reactiva (PCR), que mostró valores más elevados en el grupo Post-COVID19
(72.7±96.2 mg/dl vs 31.3±36.2 mg/dl respectivamente; p=0.042).
Grado de evolución de la AA diagnosticada intraoperatoriamente y tiempo quirúrgico.
El número de pacientes con AA complicada en forma de peritonitis fue superior en aquellos
intervenidos tras la declaración el estado de alarma cuando se comparó con aquellos intervenidos
previamente al mismo (32 %vs 7.3% respectivamente; p=0.015). No se encontraron diferencias
respecto al tiempo quirúrgico, desde el inicio de la incisión/es hasta el cierre de la/s misma/s en
ambos grupos (53.122.1 minutos vs 52.528.5 minutos; p>0.286; Pre-COVID19 y Post-
COVID19 respectivamente).
Estancia media hospitalaria.
De la misma forma, se analizó la estancia media hospitalaria según los días de ingreso
postoperatorio que el paciente estuvo en el hospital en cada grupo definido según la declaración
del estado de alerta en España. El grupo Post-COVID19 presentó un ingreso más prolongado que
el grupo Pre-COVID19 (5.6±5.9 días vs 3.2±4.3 días respectivamente; p=0.041).
Complicaciones.
Se observaron más complicaciones, de manera global, en el grupo Post-COVID19 que en el grupo
Pre-COVID19 (20 vs 9.8%; p=0.239). Los resultados se muestran en la Tabla 3.
Discusión
Nuestro estudio demostró que las apendicectomías realizadas tras la declaración del estado de
alarma en España mostraron un grado de evolución más avanzado (peritonitis), que aquellas que
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se realizaron previas a la declaración del estado de alarma. Este hallazgo se vio reforzado por el
aumento de tiempo desde el inicio de la clínica hasta el diagnóstico y cirugía en los pacientes que
fueron intervenidos después del inicio del confinamiento. Tras analizar algunas entrevistas con
los padres a su llegada al hospital, pensamos que la potencial causa de este retraso fue el miedo a
la exposición frente a los casos de coronavirus confirmados en los hospitales. Estas opiniones no
fueron analizadas en los resultados, ya que no se ha propuesto un estudio cualitativo.
También debemos recordar que el nuevo coronavirus 2, como ya se ha reflejado en varias
investigaciones, se acompaña de síntomas gastrointestinales en algunos casos, lo que puede llegar
a interferir o causar confusión a la hora de establecer el diagnóstico de una apendicitis
aguda(11,12). En todos nuestros pacientes la clínica gastrointestinal estuvo justificada por el
cuadro clínico que presentaban.
Por otro lado, los datos obtenidos muestran como el tiempo medio de estancia hospitalaria fue
mayor en aquellos pacientes intervenidos tras el estado de confinamiento, lo que supone un
problema añadido en esta situación difícil en la que medios materiales y personal sanitario
escasean. Un diagnóstico más precoz, con apendicitis aguda en un grado de evolución incipiente
acortaría la estancia hospitalaria, lo que contribuiría a la disposición de mayor numero de camas
y mayor disponibilidad de personal sanitario para contribuir y formar parte de las estrategias
destinadas a la lucha contra esta pandemia. Otra estrategia adoptada por algunos hospitales, antes
de esta pandemia, ha sido el tratamiento no quirúrgico para apendicitis aguda no complicada, con
resultados no del todo favorables como se muestra en el estudio de Huang L et al, en el que se
observa un aumento de la estancia hospitalaria y un porcentaje de los niños que terminan
requiriendo apendicectomía por mala evolución clínica(13). Además, las apendicitis que no
cumplen con las características de una AA no complicada, como las AA gangrenadas o las
peritonitis, deben ser sometidas a cirugía(14).
Es por ello que, debido a la influencia que ejerce la pandemia sobre el proceso clínico de la
apendicitis aguda, los cirujanos pediátricos, los pediatras, los médicos de atención primaria y los
familiares deben ser conscientes del problema y tratar de minimizar el retraso en el diagnóstico
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ante la aparición de síntomas, para que los pacientes lleguen en mejores condiciones y se
recuperen lo antes posible de su dolencia. De la misma forma e indirectamente, se contribuirá a
la mayor disponibilidad de medios materiales y humanos en los hospitales.
En base a las circunstancias actuales, es normal no encontrar otros estudios que evalúen la
influencia de la pandemia en la apendicitis aguda, lo que dificulta la extrapolación de los
resultados obtenido. Sin embargo, queremos dejar constancia de nuestra experiencia para tratar
de difundir entre la comunidad asistencial pediátrica el riesgo de minusvalorar o atender de forma
subóptima un cuadro habitualmente banal, pero con alto riesgo de complicaciones si se demora
su diagnóstico y tratamiento.
Es necesario fortalecer la conciencia asistencial pediátrica para que patologías de alta
prevalencia infantil como la AA no vean deteriorada su asistencia y pronóstico, por el
efecto de la grave situación epidemiológica actual, que no debe dejar desprotegido al niño
independientemente de su estado infecto-contagioso.
Limitaciones del estudio
Como limitaciones de este estudio tenemos su carácter retrospectivo, que imposibilita la
aleatorización de los pacientes, y el pequeño número de la muestra analizada en un
periodo de tiempo corto.
Bibliografía
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Incidence of Appendicitis. Ann Surg. 2017;266:23741.
3. Scholer SJ, Pituch K, Orr P, Dittus RS. Clinical outcomes of children with acute
abdominal pain. Pediatrics. 1996;98:680-5.
4. Rothrock SG, Pagane J. Acute appendicitis in children: Emergency department diagnosis
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and management. Ann Emerg Med. 2000;36:3951.
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intervención en los resultados de la apendicitis aguda. Cirugía Pediátrica. 2020;33:6570.
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system to distinguish uncomplicated from complicated acute appendicitis. Br J Surg.
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8. Hall NJ, Eaton S. Non-operative management of appendicitis in children. Arch Dis Child.
2018;103:498502.
9. Minneci PC, Mahida JB, Lodwick DL, Sulkowski JP, Nacion KM, Cooper JN, et al.
Effectiveness of patient choice in nonoperative vs surgical management of pediatric
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the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic. J Laparoendosc Adv
Surg Tech. 2020;30:356-357.
11. Sun D, Li H, Lu XX, Xiao H, Ren J, Zhang FR, et al. Clinical features of severe pediatric
patients with coronavirus disease 2019 in Wuhan: a single center’s observational study.
World J Pediatr. 2020.
12. Zhou Z, Zhao N, Shu Y, Han S, Chen B, Shu X. Effect of gastrointestinal symptoms on
patients infected with COVID-19. Gastroenterology.2020.
13. Huang L, Yin Y, Yang L, Wang C, Li Y, Zhou Z. Comparison of Antibiotic Therapy and
Appendectomy for Acute Uncomplicated Appendicitis in Children: A Meta-analysis.
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Guidelines for referral to pediatric surgical specialists. Pediatrics. 2002;110:18791.
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Figr-1Figuras.
Figura 1.
Pie de figura
Figura 1. Proceso de selección de pacientes.
Pacientes con Dº de AA
n=67
Pre-COVID19
n= 41
Post-COVID19
n= 25
1 exluido-->
Apendicectomía
diferida
... Esto planteó la hipótesis de un posible cambio en las características de los pacientes con apendicitis aguda: mayor demora en la consulta y, en consecuencia, una mayor incidencia de cuadros complicados y/o en estadios avanzados, con mayor tasa de complicaciones posoperatorias y tiempo de internación más prolongado. 9,[12][13][14][15] Al momento, no hemos encontrado informes nacionales sobre patologías no relacionadas con la enfermedad por coronavirus como la apendicitis aguda en el período de cuarentena estricta. En el presente estudio se analiza el impacto de la pandemia por COVID-19 en nuestra población de pacientes pediátricos con abdomen agudo quirúrgico secundario a apendicitis aguda durante el período de cuarentena estricta. ...
... Algunos centros describen una disminución de casos, y asocian esta reducción a una menor cantidad de consultas de los pacientes en las centrales de emergencia. 12,16 Otros grupos mostraron una consulta más tardía por causas diferentes a la infección por coronavirus en este período, lo que se asoció a una mayor tasa de apendicitis perforadas y complicadas. 13 En nuestro centro, no se observó una diferencia significativa respecto al tiempo a la consulta desde el inicio de los síntomas, ni respecto al estadio de la enfermedad. ...
Article
Full-text available
Impact of the pandemic Covid-19 on the presentation of children with Apendicitis
... However, all our analyzed patients had symptoms justified by the surgical pathology, in addition to the fact that the longest delay was after establishing the pre-surgical protocol, then this delay in entering the operating room would seem to be more related to waiting for the result of the pre surgical swabbing than with late diagnosis.In the study by Velayos M., et al. pediatric patients with acute appendicitis were evaluated in the months before and after the declaration of the pandemic in Spain. They saw a greater number of patients who consulted with fever, higher percentage of peritonitis, longer hospital stay and higher percentage of postoperative complications[6]. None of this conclusions was seen in our study.Regarding the chosen boarding technique, the conventional boarding technique has been used more in our study, different from what was observed in the study of Velayos M., et al. in which in the pre-pandemic era the laparoscopic technique[6] has been used more. ...
... They saw a greater number of patients who consulted with fever, higher percentage of peritonitis, longer hospital stay and higher percentage of postoperative complications[6]. None of this conclusions was seen in our study.Regarding the chosen boarding technique, the conventional boarding technique has been used more in our study, different from what was observed in the study of Velayos M., et al. in which in the pre-pandemic era the laparoscopic technique[6] has been used more. The most recommended boarding during the pandemic is controversial. ...
... Volume 27 Issue 23 resulted in pelvic abscess, bowel obstruction, and sepsis [74]. Delayed presentation of children with acute appendicitis at the ED may increase the morbidity related to a common childhood condition, leading to increased complications and poor outcomes [75,76]. Although complicated courses have arisen, an Italian study noticed a reduction in the total number of acute appendicitis cases. ...
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Background : Acute appendicitis (AA) is one of the most common emergencies in general surgery worldwide. During the pandemic, a significant decrease in the number of accesses to the emergency department for AA has been recorded in different countries. A systematic review of the current literature sought to determine the impact of Coronavirus Disease 2019 (COVID-19) on hospital admissions and complications of AA. Method : A systematic search was undertaken to identify repeated cross-sectional studies reporting the management of AA during the COVID-19 pandemic (index period) as compared to the previous year, or at the turn of lockdown (reference period). Data were abstracted on article (country of origin) and patients characteristics (adults, children [i.e. non adults, <18-year-old]), or mixed population) within the two given timeframes, including demographics, number of admissions for AA, number of appendectomies, and complicated appendectomies. Results : Of 201 full-text articles assessed for eligibility, 54 studies from 22 world countries were included. In total, 27 (50%) were conducted on adults, 12 (22%) on children, and 15 (28%) on a mixed patients population. The overall rate ratio of admissions for AA between the two periods was 0.94 (95%CI, 0.75-1.17), with significant differences between studies on adults (0.90 [0.74-1.09]), mixed population (0.50 [0.27-0.90]), and children (1.50 [1.01-2.22]). The overall risk ratio of complicated AA was 1.65 (1.32-2.07), ranging from 1.32 in studies on children, to 2.45 in mixed population. Conclusion : The pandemic has altered the rate of admissions for AA and appendectomy, with parallel increased incidence of complicated cases in all age groups.
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For survivors of the COVID-19 disease, defeating the virus is just the beginning of a long road to recovery. The virus’s inducibility and catastrophic effects are distributed in multiple organs. The induction of cytokine storms in COVID-19 patients is due to the interaction of the SARS-CoV-2 virus and the host receptor, leading to various immunopathological consequences that might eventually lead to death. So far, it has hit tons of people across the world, but there is still no effective treatment. Patients facing the complications of COVID-19 after recovering have shown extensive clinical symptoms similar to previously circulating coronaviruses. Previous knowledge, and literature have opened up ways to treat this disease and manage post-COVID-19 complications, which poses a severe challenge to health system globally and may exacerbate the fragmentation of diseases. The use of steroids, as a treatment, showed various health problems and side-effects in COVID-19 patients. This review substantially discusses various post-COVID-19 complications observed, adjunctive therapies used along with common COVID-19treatment and spotlighted their side effects and consequences. This review provides latest literature on COVID-19 which emphasizes the subsequent complications in various organs, side-effects of drug, and alternative regimes that were used to treat COVID-19.
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The global spread of the novel severe acute respiratory syndrome coronavirus 2 has had serious consequences in terms of patient morbidity and mortality and overburdened health care systems as well as the socioeconomic implications. In the absence of effective therapies and vaccinations during the viral outbreak, the major and most concise means to control viral spread is spread prevention. Although information concerning the impact of severe acute respiratory syndrome coronavirus 2 on pediatric surgical patients has greatly expanded, relevant comprehensive studies are scarce. However, pandemic related morbidity has increased, while under normal circumstances mortality could have been minimized.
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Background: The Coronavirus Disease 2019 (COVID-19) pandemic has impacted volume, management strategies and patient outcomes of acute appendicitis. The aim of this systematic review and meta-analysis was to evaluate whether the COVID-19 pandemic resulted in higher incidence of complicated appendicitis in children presenting with acute appendicitis compared to the pre-COVID-19 period. The secondary aim was to investigate the proportion of the patients treated by non-operative management (NOM). Methods: A systematic search of four scientific databases was performed. The search terms used were (coronavirus OR SARS-CoV-2 OR COVID-19 OR novel coronavirus) AND (appendicitis). The inclusion criteria were all patients aged <18 years and diagnosed with acute appendicitis during the COVID-19 and pre-COVID-19 periods. The proportion of children presenting with complicated appendicitis and the proportion of children managed by NOM was compared between the two groups. The Downs and Black scale was used for methodological quality assessment. Results: The present meta-analysis included thirteen studies (twelve retrospective studies and one cross-sectional study). A total of 2782 patients (1239 during the COVID-19 period) were included. A significantly higher incidence of complicated appendicitis (RR = 1.63, 95% CI 1.33-2.01, p < 0.00001) and a significantly higher proportion of children managed via the NOM (RR = 1.95, 95% CI 1.45-2.61, p < 0.00001) was observed in patients during the COVID-19 pandemic when compared to the pre-COVID-19 period. Conclusion: There is a significantly higher incidence of complicated appendicitis in children during the COVID-19 pandemic than in the pre-COVID-19 period. Additionally, a significantly higher proportion of children was managed via the NOM during the pandemic in comparison to the pre-pandemic period.
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Background Patient attendance at emergency departments (EDs) during the COVID-19 pandemic outbreak has decreased dramatically under the “stay at home” and “lockdown” restrictions. By contrast, a notable rise in severity of various surgical conditions was observed, suggesting that the restrictions coupled with fear from medical facilities might negatively impact non-COVID-19 diseases. This study aims to assess the incidence and outcome of complicated appendicitis (CA) cases during that period.MethodsA retrospective study comparing the rate and severity of acute appendicitis (AA) cases during the COVID-19 initial outbreak in Israel during March and April of 2020 (P20) to the corresponding period in 2019 (P19) was conducted. Patient data included demographics, pre-ED status, surgical data, and postoperative outcomes.ResultsOverall, 123 patients were diagnosed with acute appendicitis, 60 patients during P20 were compared to 63 patients in P19. The rate of complicated appendicitis cases was significantly higher during the COVID-19 Lockdown with 43.3% (26 patients) vs. 20.6% (13 patients), respectively (p < 0.01). The average delay in ED presentation between P20 and P19 was 3.4 vs. 2 days (p = 0.03). The length of stay was 2.6 days in P20 vs. 2.3 days in P19 (p = 0.4), and the readmission rate was 12% (7 patients) vs. 4.8% (3 patients), p = 0.17, respectively. Logistic regression demonstrated that a delay in ED presentation was a significant risk factor for complicated appendicitis (OR 1.139, CI 1.011–1.284).Conclusion The effect of the COVID-19 initial outbreak and Lockdown coupled with hesitation to come to medical facilities appears to have discouraged patients with acute appendicitis from presenting to the ED as complaints began, causing a delay in diagnosis and treatment, which might have led to a higher rate of complicated appendicitis cases and a heavier burden on health care systems.
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IDENTIFICAÇÃO DAS CONDUTAS TOMADAS NO TRATAMENTO DA SÍNDROME DE FOURNIER EM HOSPITAL SECUNDÁRIO
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O TRATAMENTO CIRÚRGICO DA OBESIDADE
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Objective: Time to treatment initiation is a key element to be considered in infectious pathologies such as acute appendicitis (AA). There are few articles in the literature analyzing the relationship between early pre-surgical antibiotic treatment initiation and complication occurrence in AA. Our objective is to analyze such influence and the effects of late treatment initiation. Materials and methods: A retrospective, observational study was carried out in children undergoing surgery for AA between 2017 and 2018. Demographic variables, time to antibiotic treatment initiation, time to surgery, and postoperative complications were analyzed. Results: 592 patients with a median 12-month follow-up were included in the study. Antibiotic treatment initiation in the first 8 hours following diagnosis prevents complications [OR 0.24 (95% CI: 0.07-0.80)] and dramatically reduces the occurrence of intra-abdominal abscess from 25.0% to 5.5% (p=0.03). Antibiotic treatment initiation in the first 4 hours following diagnosis significantly reduced wound infection rate in non-overweight patients [2.9% vs. 13.6%; OR 0.19 (95% CI: 0.045-0.793); p=0.042]. Surgery within the first 24 hours following diagnosis reduced the proportion of advanced AA (gangrenous appendicitis and peritonitis) from 100% to 38.6% (p=0.023). Conclusions: Antibiotic treatment initiation in the first 4 hours following AA prevented the occurrence of post-surgical complications, especially in non-overweight patients. An adequate clinical approach and an early assessment by the pediatric surgeon are key to reduce the morbidity associated with AA.
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Importance: Antibiotic therapy for acute uncomplicated appendicitis is effective in adult patients, but its application in pediatric patients remains controversial. Objective: To compare the safety and efficacy of antibiotic treatment vs appendectomy as the primary therapy for acute uncomplicated appendicitis in pediatric patients. Data sources: The PubMed, MEDLINE, EMBASE, and Cochrane Library databases and the Cochrane Controlled Trials Register for randomized clinical trials were searched through April 17, 2016. The search was limited to studies published in English. Search terms included appendicitis, antibiotics, appendectomy, randomized controlled trial, controlled clinical trial, randomized, placebo, drug therapy, randomly, and trial. Study selection: Randomized clinical trials and prospective clinical controlled trials comparing antibiotic therapy with appendectomy for acute uncomplicated appendicitis in pediatric patients (aged 5-18 years) were included in the meta-analysis. The outcomes included at least 2 of the following terms: success rate of antibiotic treatment and appendectomy, complications, readmissions, length of stay, total cost, and disability days. Data extraction and synthesis: Data were independently extracted by 2 reviewers. The quality of the included studies was examined in accordance with the Cochrane guidelines and the Newcastle-Ottawa criteria. Data were pooled using a logistic fixed-effects model, and the subgroup pooled risk ratio with or without appendicolith was estimated. Main outcomes and measures: The primary outcome was the success rate of treatment. The hypothesis was formulated before data collection. Results: A total of 527 articles were screened. In 5 unique studies, 404 unique patients with uncomplicated appendicitis (aged 5-15 years) were enrolled. Nonoperative treatment was successful in 152 of 168 patients (90.5%), with a Mantel-Haenszel fixed-effects risk ratio of 8.92 (95% CI, 2.67-29.79; heterogeneity, P?=?.99; I2?=?0%). Subgroup analysis showed that the risk for treatment failure in patients with appendicolith increased, with a Mantel-Haenszel fixed-effects risk ratio of 10.43 (95% CI, 1.46-74.26; heterogeneity, P?=?.91; I2?=?0%). Conclusions and relevance: This meta-analysis shows that antibiotics as the initial treatment for pediatric patients with uncomplicated appendicitis may be feasible and effective without increasing the risk for complications. However, the failure rate, mainly caused by the presence of appendicolith, is higher than for appendectomy. Surgery is preferably suggested for uncomplicated appendicitis with appendicolith.
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Background An outbreak of coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 was first detected in Wuhan, Hubei, China. People of all ages are susceptible to SARS-CoV-2 infection. No information on severe pediatric patients with COVID-19 has been reported. We aimed to describe the clinical features of severe pediatric patients with COVID-19.Methods We included eight severe or critically ill patients with COVID-19 who were treated at the Intensive Care Unit (ICU), Wuhan Children’s Hospital from January 24 to February 24. We collected information including demographic data, symptoms, imaging data, laboratory findings, treatments and clinical outcomes of the patients with severe COVID-19.ResultsThe onset age of the eight patients ranged from 2 months to 15 years; six were boys. The most common symptoms were polypnea (8/8), followed by fever (6/8) and cough (6/8). Chest imaging showed multiple patch-like shadows in seven patients and ground-glass opacity in six. Laboratory findings revealed normal or increased whole blood counts (7/8), increased C-reactive protein, procalcitonin and lactate dehydrogenase (6/8), and abnormal liver function (4/8). Other findings included decreased CD16 + CD56 (4/8) and Th/Ts*(1/8), increased CD3 (2/8), CD4 (4/8) and CD8 (1/8), IL-6 (2/8), IL-10 (5/8) and IFN-γ (2/8). Treatment modalities were focused on symptomatic and respiratory support. Two critically ill patients underwent invasive mechanical ventilation. Up to February 24, 2020, three patients remained under treatment in ICU, the other five recovered and were discharged home.Conclusions In this series of severe pediatric patients in Wuhan, polypnea was the most common symptom, followed by fever and cough. Common imaging changes included multiple patch-like shadows and ground-glass opacity; and a cytokine storm was found in these patients, which appeared more serious in critically ill patients.
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Whilst appendicectomy has been considered the mainstay of treatment for children with acute appendicitis for many decades there has been a great deal of recent interest in non-operative treatment (NOT) with antibiotics alone. Initial results suggest that many children with appendicitis can indeed be safely treated with NOT and can be spared the surgeon’s knife. Many as yet unanswered questions remain however before NOT can be considered a realistic and reliable alternative to the surgery. This review summaries current knowledge and understanding of the role of NOT in children with appendicitis and outlines and discusses the outstanding knowledge gaps.
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Objective: We compared the incidence of appendicitis or appendectomy across the world and evaluated temporal trends. Summary background data: Population-based studies reported the incidence of appendicitis. Methods: We searched MEDLINE and EMBASE databases for population-based studies reporting the incidence of appendicitis or appendectomy. Time trends were explored using Poisson regression and reported as annual percent change (APC) with 95% confidence intervals (CI). APC were stratified by time periods and pooled using random effects models. Incidence since 2000 was pooled for regions in the Western world. Results: The search retrieved 10,247 citations with 120 studies reporting on the incidence of appendicitis or appendectomy. During the 21st century the pooled incidence of appendicitis or appendectomy (in per 100,000 person-years) was 100 (95% CI: 91, 110) in Northern America, and the estimated number of cases in 2015 was 378,614. The pooled incidence ranged from 105 in Eastern Europe to 151 in Western Europe. In Western countries, the incidence of appendectomy steadily decreased since 1990 (APC after 1989=-1.54; 95% CI: -2.22, -0.86), whereas the incidence of appendicitis stabilized (APC=-0.36; 95% CI: -0.97, 0.26) for both perforated (APC=0.95; 95% CI: -0.25, 2.17) and nonperforated appendicitis (APC=0.44; 95% CI: -0.84, 1.73). In the 21st century, the incidence of appendicitis or appendectomy is high in newly industrialized countries in Asia (South Korea pooled: 206), the Middle East (Turkey pooled: 160), and Southern America (Chile: 202). Conclusions: Appendicitis is a global disease. The incidence of appendicitis is stable in most Western countries. Data from newly industrialized countries is sparse, but suggests that appendicitis is rising rapidly.
Article
Importance Current evidence suggests that nonoperative management of uncomplicated appendicitis is safe, but overall effectiveness is determined by combining medical outcomes with the patient’s and family’s perspective, goals, and expectations.Objective To determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children.Design, Setting, and Participants Prospective patient choice cohort study in patients aged 7 to 17 years with acute uncomplicated appendicitis presenting at a single pediatric tertiary acute care hospital from October 1, 2012, through March 6, 2013. Participating patients and families gave informed consent and chose between nonoperative management and urgent appendectomy.Interventions Urgent appendectomy or nonoperative management entailing at least 24 hours of inpatient observation while receiving intravenous antibiotics and, on demonstrating improvement of symptoms, completion of 10 days of treatment with oral antibiotics.Main Outcomes and Measures The primary outcome was the 1-year success rate of nonoperative management. Successful nonoperative management was defined as not undergoing an appendectomy. Secondary outcomes included comparisons of the rates of complicated appendicitis, disability days, and health care costs between nonoperative management and surgery.Results A total of 102 patients were enrolled; 65 patients/families chose appendectomy (median age, 12 years; interquartile range [IQR], 9-13 years; 45 male [69.2%]) and 37 patients/families chose nonoperative management (median age, 11 years; IQR, 10-14 years; 24 male [64.9%]). Baseline characteristics were similar between the groups. The success rate of nonoperative management was 89.2% (95% CI, 74.6%-97.0%) at 30 days (33 of 37 children) and 75.7% (95% CI, 58.9%-88.2%) at 1 year (28 of 37 children). The incidence of complicated appendicitis was 2.7% in the nonoperative group (1 of 37 children) and 12.3% in the surgery group (8 of 65 children) (P = .15). After 1 year, children managed nonoperatively compared with the surgery group had fewer disability days (median [IQR], 8 [5-18] vs 21 [15-25] days, respectively; P < .001) and lower appendicitis-related health care costs (median [IQR], $4219 [$2514-$7795] vs $5029 [$4596-$5482], respectively; P = .01).Conclusions and Relevance When chosen by the family, nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis, incurring less morbidity and lower costs than surgery.Trial Registration clinicaltrials.gov Identifier: NCT01718275
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The Surgical Advisory Panel of the American Academy of Pediatrics (AAP), in response to a recommendation from the AAP Subspecialty Work Group and with the collaboration of the Surgical Sections of the AAP, has created referral guidelines intended to serve as voluntary practice parameters to assist general pediatricians in determining when and where to refer their patients to pediatric surgical specialists. It is recognized that the guidelines here may be difficult to achieve. Communities vary. Specialties overlap, and more than 1 type of pediatric or other surgical specialist may be qualified to manage a particular problem. Many complex pediatric problems are optimally managed by a medical-surgical team rather than an individual surgical specialist. This does not negate the value of the guidelines, however, because the child who needs specialized surgical care is best served by the skills of the appropriate pediatric surgical specialist. Major congenital anomalies, malignancies, major trauma, and chronic illnesses in infants and children should be managed by pediatric medical and surgical specialists at pediatric referral centers. Such centers dedicated to children can provide expertise in many areas, including the pediatric medical and surgical specialties, pediatric radiology, pediatric anesthesiology, pediatric pathology, and pediatric intensive care. The optimal management of the child with complex problems, chronic illness, or disabilities requires coordination, communication, and cooperation of the pediatric surgical specialist with the child’s primary care pediatrician or physician. When a surgical condition has been identified, ideally, a pediatric surgical specialist should be called to address the issues related to this condition with the family and the respective pediatrician. In rural areas where it would be a hardship to the family and the child to travel long distances, the family in conjunction with the primary care pediatrician/physician should weigh the advantages of traveling to a center with a pediatric surgical specialist …
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Non-operative management may be an alternative for uncomplicated appendicitis, but preoperative distinction between uncomplicated and complicated disease is challenging. This study aimed to develop a scoring system based on clinical and imaging features to distinguish uncomplicated from complicated appendicitis. Patients with suspected acute appendicitis based on clinical evaluation and imaging were selected from two prospective multicentre diagnostic accuracy studies (OPTIMA and OPTIMAP). Features associated with complicated appendicitis were included in multivariable logistic regression analyses. Separate models were developed for CT and ultrasound imaging, internally validated and transformed into scoring systems. A total of 395 patients with suspected acute appendicitis based on clinical evaluation and imaging were identified, of whom 110 (27·8 per cent) had complicated appendicitis, 239 (60·5 per cent) had uncomplicated appendicitis and 46 (11·6 per cent) had an alternative disease. CT was positive for appendicitis in 284 patients, and ultrasound imaging in 312. Based on clinical and CT features, a model was created including age, body temperature, duration of symptoms, white blood cell count, C-reactive protein level, and presence of extraluminal free air, periappendiceal fluid and appendicolith. A scoring system was constructed, with a maximum possible score of 22 points. Of the 284 patients, 150 had a score of 6 points or less, of whom eight (5·3 per cent) had complicated appendicitis, giving a negative predictive value (NPV) of 94·7 per cent. The model based on ultrasound imaging included the same predictors except for extraluminal free air. The ultrasound score (maximum 19 points) was calculated for 312 patients; 105 had a score of 5 or less, of whom three (2·9 per cent) had complicated appendicitis, giving a NPV of 97·1 per cent. With use of novel scoring systems combining clinical and imaging features, 95 per cent of the patients deemed to have uncomplicated appendicitis were correctly identified as such. The score can aid in selection for non-operative management in clinical trials. © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd.