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Diagnostic Laparoscopy and Appendicectomy for Children with Chronic Right Iliac Fossa Pain – An Aggregate Analysis

Paul Charlesworth, Anies Mahomed
Department of Paediatric Surgery, Royal Alexandra Hospital for Sick Children, Brighton, United Kingdom

 

 

Correspondence

Mr Anies Mahomed
Department of Paediatric Surgery
Royal Alexandra Hospital for Sick Children
Eastern road, Brighton, BN2 5BE, United Kingdom
tel: 01273 696955
fax: 01273 523120
e-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Introduction: Chronic right iliac fossa pain is a common paediatric complaint yet there are relatively few published series on its management. The aim of this paper is to evaluate a cohort of patients presenting with chronic right iliac fossa pain and managed by laparoscopy. A review of the current literature is presented.

Material and methods: Data was extracted from a prospective database of laparoscopic appendicectomy patients who met the criteria for chronic right iliac fossa pain. A retrospective case note review was undertaken. A literature search of published material on the condition was performed using Medline and Pubmed.

Result: Over a 4 year period from October 2003 sixteen children underwent laparoscopic appendicectomy for chronic right iliac fossa pain. Thirteen (81%) were female. The median age was 12 years 2 months with range of 9 years 6 months to 14 years 4 months. No patients had undergone previous abdominal surgery. The duration of pre-operative symptoms was 10 months, range (1-30). All preoperative laboratory and radiological investigations were inconclusive. The appendix was macroscopically normal in 14/16 (88%) patients. Four patients were noted to have adhesions. There was early improvement in 14/16 patients, which is a correlation of 88% between procedure and symptom resolution. This figure had improved to a 100% over the medium term. Median follow-up is 19 months, range 1-47. The correlation between symptoms and positive finding on histology or at laparoscopy was 100%. A literature review of the paediatric cases revealed 159 predominantly female patients. Symptom resolution following appendicectomy ranged between 70.6 and 90%. Positive histology was present between 30 and 86% of patients. 

Conclusion: The evidence from this study and the literature supports laparoscopic appendicectomy in all patients presenting with chronic right iliac fossa pain following negative radiological and serological investigations. Symptomatic improvement can be expected to be 88% immediately and up to 100% in the long term.

Key words: chronic right iliac fossa pain, appendicitis, laparoscopy.

 

Introduction

Non-specific abdominal pain is the commonest diagnosis for children presenting with abdominal discomfort to hospital [1]. Chronic right iliac fossa (CRIF) pain is well described in the adult population [2], with women of childbearing age particularly prone to this condition. This can be related to either gynaecological or appendiceal pathology [3,4].

In children, acute right iliac fossa is a common complaint and in many cases the symptoms resolve spontaneously. However a population exists where symptoms persist and no pathology is identified. Psychological pathology and stress or anxiety can manifest itself as functional abdominal pain syndrome [5,6]. Children with this condition are more likely to take time off school increasing parental anxiety [7]. Where psychological cause is thought unlikely, routine investigations to exclude common conditions are routinely performed.

There is evidence to support the hypothesis that chronic appendicitis/appendiceal colic improves in children following appendicectomy [8]. This paper presents original scientific work which defines patient demographics, the natural history of this condition and assesses the value of laparoscopic appendicectomy in its treatment.

appendic 1

Figure 1.  Adhesive bands between caecum and lateral abdominal wall in child presenting with chronic right iliac fossa pain. 

appendic 2

Figure 2. Pus in the lumen noted on histology in a macroscopically normal appearing appendix

 Material and methods

A prospective spreadsheet is used as a database for all patients undergoing laparoscopic surgery at our university affiliated tertiary paediatric surgical unit. Intra-operative details, histology and outpatient follow-up are recorded routinely. Details of patients undergoing laparoscopic appendicectomy for chronic right iliac fossa pain were obtained from the database and complemented with a retrospective case-note review. Inclusion criteria were all patients who had right iliac fossa pain lasting greater than 4-weeks, who presented acutely or to outpatient clinic. Four weeks was set as a time period to allow for consistency in literature comparison. The notes and database were studied for patient profile, symptom duration, number of preoperative clinic visits/attendances to acute medical services for the same condition and investigations. Routine investigations included blood markers ( full blood count, urea and electrolytes, liver profile and inflammatory markers to include CRP and ESR), radiological investigations (abdominal x-ray and ultrasound scan and upper gastrointestinal endoscopy. Additional data analysed were intra and postoperative outcomes and histology. A correlation between symptoms pre and post surgery and positive finding at laparoscopy or histology were investigated. Positive histology included signs of acute or chronic inflammation, pus within the wall of the appendix, presence of a faecolith, excessive mucus, lymphoid aggregates and congested appendix. A literature search was undertaken on Pubmed and Medline and references of previous published literature were scrutinised.

Result

Over a 4 year period between October 2003 and Octover 2007, sixteen children underwent laparoscopic appendicectomy for chronic right iliac fossa pain. All but one patient were referred to the paediatric surgery out-patient clinic and were investigated for chronic right iliac fossa pain before a diagnostic laparoscopy and appendicectomy was performed. One patient presented with acute symptoms but on further detailed questioning had a history of right iliac fossa pain for 6 months. Data are presented as median and range and is summarised in Table 1.

Table 1. Summary of data 

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Thirteen (81%) were female. The median age was 12 years 2 months, range 9 years 6 months to 14 years 4 months. No patients had undergone previous abdominal surgery.

The duration of pre-operative symptoms was 10 (1-30) months. The number of clinic visits or admissions before definitive diagnosis was 4 (0-11). Cyclical pain and ‘Mittlesmertz’ were routinely excluded in post pubertal female patients. All patients failed to demonstrate signs of peritonitis, rebound or guarding on clinical examination. The fifteen patients that were referred through clinic had routine serum laboratory investigations including full blood count, urea and electrolytes, liver function and C-reactive protein, all of which were within the normal range. All 15 had an abdominal ultrasound, four patients underwent barium studies, two patients had abdominal radiographs, one patient had upper and lower endoscopy and one patient had a white cell scan. All preoperative radiological and interventional investigations were reported as normal.

All sixteen patients underwent a standard three port laparoscopic appendicectomy with the use of endoloops to secure the appendix base. Operative time was 40 (30 – 90) minutes. The appendix was macroscopically normal in 14/16 (88%) patients. Four patients were noted to have adhesions at operation, two of which had lateral pelvic bands and one between the caecum and anterior abdominal wall. There were no appendix masses, free fluid was only present in the patient presenting acutely. There were no instances of intraoperative bleeding or serious complications.

There was one minor visceral injury, which had no post-operative consequences. Postoperative analgesia consisted of simple non-steroidal analgesics and paracetamol, with only two patients requiring morphine. Median time to full feeds was 6 (4-48) hours. Postoperative stay ranged from same day discharge to two days. Six patients underwent day-stay procedure, eight patients stayed for one day and two patents stayed for two days. One of the patients that stayed for two days was the patient who was admitted acutely. There were no episodes of wound sepsis, or dehiscence. There was an improvement in 14/16 patients, which is a correlation of 88% between procedure and freedom from symptoms post operatively. Median follow-up was 19 (1-47) months. One patient developed chronic fatigue syndrome secondary to a viral infection. This lasted for two years but he is currently well and discharged from medical follow-up. One patient experienced mild recurrent abdominal pain and nausea for five months post surgery, on last clinic appointment she was pain free at 15 months. The patient who presented acutely had two episodes of scar pain, which had resolved on recent follow-up of three months. Ultimately all patients got better.

Histology of the appendix was normal in seven patients. Of these seven patients; two had paraovarian cysts which were excised, two had macroscopic lymphoid hyperplasia noted at surgery, two were noted to have overlying bands which were divided and one had an appendicolith removed at the time of surgery. The remaining nine had positive histology. The correlation between symptoms and positive finding on histology or at laparoscopy was 100%.

Literature review

There are six published series in the paediatric population, totalling 161 patients[8-13]. The age of the patients ranged between 2 and 20 years with a range of means between 11.4 and 13.3 years. Two patients were lost to follow-up and of the remaining patients 109/159 were female (68.5%). The duration of symptoms ranged from 1 to 84 months with the means varying between 1.84 and 48 months. All series report extensive radiological and serological investigation with minimum results. Four of the six series report a laparoscopic approach, with 83/159 (52.2%) patients having a laparoscopy with appendicectomy and 76/159 (47.7%) undergoing open appendicectomy. Two of the patients in one of the laparoscopic series had previously undergone appendicectomy. Positive findings at operation ranges between 0 and 92.3%. Positive histological findings range between 30.8 and 82%. Resolution of symptoms varies between 70.4% and 98%. Reported mean follow-up ranges between 1 year 4 months and 4 years 4 months. The results are summarised in table 2.

Table 2. Paediatric Series of CRIF pain.

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Discussion

Chronic right iliac fossa, right lower quadrant or pelvic pain in the paediatric population is a common clinical entity. With the widespread use of laparoscopy a new diagnostic approach is being undertaken. Despite this there have been few clinical series published. Gorenstein et al prospectively analysed 1,125 children presenting with abdominal pain, of these, 26 children presented with recurrent right lower quadrant pain termed ‘appendiceal colic’. These children underwent elective open appendicectomy [8]. The senior author has published a series of 16 children demonstrating the benefit of removal of the appendix at diagnostic laparoscopy in children with CRIF pain [10]. This message was repeated by Stringel et al. although with a much higher complication rate [11]. Sylianos et al concluded that laparoscopy was an accurate technique for evaluation and treatment of children with recurrent abdominal pain [13]. Kolts et al. described 44 children with chronic right lower abdominal pain who underwent laparoscopic exploration and appendicecto-my. They demonstrated a resolution of symptoms in 70% of patients [9]. The largest series was by Stevenson. Fiftytwo consecutive children undergoing open appendicectomy for appendiceal colic were followed up for a mean of 4 years. There was a 98% resolution of symptoms [12].

In the paediatric population patients are mainly female. In this series 13/16 (81%) are female. This is similar to our previous series where 9/11 (82%) were female [10]. The number of female patients in the literature varies between 53.8% and 87%. The age of patients varies between 10 and 17 years and symptoms persist for a period of between 2 and 12 months before either laparoscopy or open appendicectomy is performed [8,9,11-13].

There was an 88% instant resolution of symptoms in this series compared with 72% in a previous series by the principal author. In the paediatric population the correlation between laparoscopic appendicectomy and resolution of symptoms ranges between 70% and 76% [9, 10, 13], which compares to a symptom resolution of between 88.5% and 98% when open appendicectomy is performed [8,12]. Kolts et al. were able to demonstrate a higher statistical difference in resolution of symptoms in those who were not attending psychiatric clinic and those with positive histology [9] This finding is echoed in our original series with the patients with negative histology and intraoperative findings undergoing psychiatric evaluation [10], and other publications where those with positive histology were more likely to have an improved outcome [13]. Patients who do not obtain symptom resolution following surgery should be considered for cognitive behavioural procedures [14].

The positive findings from radiological investigations, including CT scanning remains low, and has been calculated at 5% [13], in this population. It is an important negative finding, occasionally diagnosing ovarian pathology [8]. The use of barium studies to diagnose appendiceal colic has also been employed although it’s diagnostic accuracy is doubtful [8].

In our series we had a positive correlation of histology in nine patients (56%). This included presence of pus within the appendix wall ( fig. 2), inflammatory cells, presence of granulomas, presence of a facolith and lymphoid aggregates. Those patients without positive histology all had positive findings at laparotomy. In our earlier series 82% had positive histology. Positive histology in the literature ranges between 30.8% to 82% of patients [8,9] with similar histological findings to our series, that of chronic inflammatory changes or lymphoid hyperplasia. Positive histology has dropped between our two series which reflects the lower threshold and hence increasing role of laparoscopy as a diagnostic tool. That notwithstanding, symptom resolution and postitve findings at laparoscopy are higher. This both demonstrates the role of diagnostic laparoscopy and the therapeutic affect of appendicectomy in this cohort.

Positive findings other than the appendix in our series were due to para-ovarian cysts in two patients, adhesional bands in two patients, the remaining three were noted to have appendix related macroscopic findings; lymphoid hyperplasia and a faecolith in one. The significance of adhesive bands in the precinct of the appendix to previous pathology within that organ can only be insinuated. In our previous series one patient had Enterobius vermicularis parasites and one patient had normal histology with unresolved symptoms at follow-up [10]. Macroscopic lymphadenopathy in the mesoappendix is a common finding in the paediatric literature and might well be related to chronic changes within the appendix. Stylianos et al reported three Meckel’s diverticula, one inguinal hernia one urachal cyst and one parafallopian tube cyst in a series of 15 patients [13]. In a series of thirteen patients; Stringel reported inflammatory bowel disease in two, fallopian tube cysts in two, torsion of an ovarian cyst in one and salpingitis in one [11]. Gorenstein noted paraovarian cysts on ultrasound scan in three patients prior to appendiciectomy but doesn’t note whether these were treated or whether symptoms persisted in these patients. Operative findings other than appendiceal showed one ovarian cyst, one fimbrial cyst and one case of ileoileal intusssusception. One patient in this series was subsequently diagnosed with celiac disease [8]. In Kolts’ series of 44 patients, six had Meckel’s diverticulum, four had adhesions involving the caecum and two had hernias and one had an ovarian cyst. Histological differences in this series included on case of a carcinoid tumour and one case of Crohn’s disease [9].

In the acute setting there is a negative appendicectomy rate of 22% for laparoscopic and 15% for open procedure [15]. The question in the adult literature remains, whether a ‘normal’ appendix should be left at laparoscopy for acute appendicits [15- 17]. Traditionally the appendix was always removed following a Grid-Iron incision to avoid diagnostic confusion in the future. Macroscopic assessment at laparoscopy has a false negative of 3% in a predominantly paediatric population according to a large meta analysis [15]. Laparoscopic appendicectomy has improved outcomes with increasing experience [18] and should be performed where diagnostic doubt arises. If a diagnostic laparoscopy is undertaken in the acute setting, it has been shown that patients benefit from removal of a ‘normal’ looking appendix with no increased morbidity or mortality [19].

However laparoscopic appendicectomy is not without risk and there is a reported 6.5% conversion and 4.7% complication rate [15]. The most common pathology seen at diagnostic laparoscopy for adults with chronic abdominal pain is adhesions. Symptomatic relief following laparoscopic division of adhesions varies between 71% and 90%[20-25]. Morbidity is significantly related to age and symptom duration[23]. There is a mortality of 1%[24]. In a study of women admitted with non-specific abdominal pain randomly assigned to laparoscopic assessment versus observation. The group assigned to laparoscopy had a higher rate of diagnosis 79% versus 45%, a shorter hospital stay and lower recurrence rate[26]. There is an 80% success rate in laparoscopic surgery[27] for chronic pelvic pain in women, and an appendicectomy should be performed if right lower quadrant pain is part of the pain profile [4] In a study of 269 women with chronic pelvic pain, laparoscopic appendicectomy was performed in 102 women. Ninety two women had symptomatic relief. Histology varied between endometriosis of the appendix tip (3.78%), obliteration of the appendix lumen (24.6%) and adhesions (6.93%). The authors concluded that the appendix is the key organ in management of chronic pelvic pain[28].

Conclusion

We recommend that a diagnostic laparoscopy is performed for children presenting with right iliac fossa pain lasting longer than four weeks, where routine bloods and abdominal ultrasound scan have failed to produce a diagnosis. Removal of a macroscopically normal appendix remains controversial. The evidence from this study supports laparoscopic appendicectomy in all children, even if the appendix appears macroscopically normal. The only exception to this should be children in whom the appendix is anticipated to be necessary for a bowel or bladder conduit. A randomised controlled trial would be useful to support the proposal that all macroscopically normal appendixes should be removed in chronic right iliac fossa pain. Following diagnostic laparoscopy and appendicectomy, between 70% and 98% of this population can expect symptomatic improvement in the short term with the figure rising to 100% over the longer term. 

 

 

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