Primary non-surgical treatment in pediatric complicated appendicitis: does abscess size matter?

Primary emergency appendectomy in children with perityphlitic abscess carries a substantial risk of major complications. Depending on the abscess size, the optimal management of complicated appendicitis with perityphlitic abscess in children remains unclear. This study specifically aimed to investigate the treatment modality of perityphlitic abscesses in pediatric population. Therefore, a retrospective study analyzed all children aged 1 to 17 years, who underwent appendectomy for appendicitis over a ten-year period at a Northern European pediatric care center. Patients with perityphlitic abscess were identified, and their treatment and clinical outcome further analyzed. From November 2012 to November 2022, out of 1,399 children with appendicitis 31 (2.2%) presented with perityphlitic abscess formation. All patients with perityphlitic abscess received primary treatment with intravenous antibiotics followed by interval appendectomy. Median diameter size of abscess at the time of admission was 4.5 cm (IQR 3.3, 6.0). 93.5% of the study population clinically improved after median eight-days-intravenous antibiotic treatment (IQR 7.0, 9.0) and underwent interval appendectomy median 91.0 days (IQR 73.0, 110.0) after the initial hospital discharge. No postoperative complications in interval appendectomies occurred. 85% of resected appendices showed histopathological remaining stages of inflammation at the time of interval appendectomy. A two-step approach consisting of eight days of intravenous antibiotic therapy followed by interval laparoscopic appendectomy after 3 months represents a feasible and safe treatment strategy for children with perityphlitic abscesses without signs of generalized peritonitis.