Evaluation of a Possible Inflammatory Response after Appendectomy for Non-Perforated Appendicitis in Children

Abstract

background: The inflammatory process in the post-appendectomy period is not well characterized. In a pilot study, we prospectively followed the kinetics of different inflammatory mediators before and after appendectomy in children, and compared the results of the groups open appendectomy (OA) and laparoscopic appendectomy (LA).

Material and Methods: Levels of sP-selectin, tPA, MCP-1, IL-6, IL-8, sVCAM-1, and sCD40L were measured before appendectomy and on the next three consecutive days in the serum of 25 children (16 males and 9 females) aged 7 – 16 years (mean 12.6±2.47 years) with non-perforated acute appendicitis.

Results: LA and OA were performed in 16 and 9 patients respectively. None of the markers of inflammation differed significantly by surgical approach at any point of observation. However, sP-selectin, MCP-1 and sVCAM-1 levels were found to have significantly different postoperative kinetics with a trend towards higher values in the laparoscopic group compared to the open appendectomy group (p=0.034, p=0.016 and p=0.025, respectively).

Conclusions: The cytokines sP-selectin, MCP-1 and sVCAM-1 may play a role in the possible post-appendectomy cytokine activation after non-perforated appendicitis. Since this phenomenon is more evident after LA than after OA, the contribution of the different LA procedures has to be further investigated.

Key words

appendicitis - children - cytokines - inflammation - laparoscopic appendectomy

References

• 1 Abbas AK. Effector mechanisms of immune responses. In: Abbas AK, Lichtman AH, Pober JS. Cellular and Molecular Immunobiology. Philadelphia: WB Saunders 2000 pp: 233-339
• 2 Bergmann S, Hammerschmidt S. Fibrinolysis and host response in bacterial infections.  Thromb Haemost. 2007;  98 512-520
• 3 Bittinger F, Brochhausen C, Köhler H. Differential expression of cell adhesion molecules in inflamed appendix: correlation with clinical stage.  J Pathol. 1998;  186 422-428
• 4 Bloechle C, Kluth D, Holstein AF. A pneumoperitoneum perpetuates severe damage to the ultrastructural integrity of parietal peritoneum in gastric perforation-induced peritonitis in rats.  Surg Endosc. 1999;  13 683-688
• 5 Eriksson S, Granstrom L, Olander B. et al . Sensitivity of interleukin-6 and C-reactive protein concentrations in the diagnosis of acute appendicitis?.  Eur J Surg. 1995;  161 41-45
• 6 Erkasap S, Ates E, Ustuner Z. Diagnostic value of interleukin-6 and C-reactive protein in acute appendicitis.  Swiss Surg. 2000;  6 169-172
• 7 Faraway J. Extending the Linear Model with R.  Chapman and Hall/CRC. 2006;  233-234
• 8 Gabay C, Kushner I. Acute-phase proteins and other systemic responses to inflammation.  N Engl J Med. 1999;  340 448-454
• 9 Glasgow RE, Fingerhut A, Hunter J. SAGES Appropriateness Conference: a summary.  Surg Endosc. 2003;  17 1729-1734
• 10 Goodwin AT, Swift RI, Bartlett MJ. Can serum interleukin-6 levels predict the outcome of patients with right iliac fossa pain?.  Ann R Coll Surg Engl. 1997;  79 130-133
• 11 Hastie T. Generalized Additive Models – R package, 2005; Version 0.94. 
• 12 Ignacio RC, Burke R, Spencer D. Laparoscopic versus open appendectomy: what is the real difference? Results of a prospective randomized double-blinded trial.  Surg Endosc. 2004;  18 334-337
• 13 Kuebler JF, Kos M, Jescha NK. et al . Carbon dioxide suppresses macrophage superoxide anion production independent of extracellular pH and mitochondrial activity.  J Pediatr Surg. 2007;  42 244-248
• 14 Lehmann EL, Romano JP. Testing Statistical Hypotheses. New York: Springer 2005 pp: 513-517
• 15 Mattioli G, Castagnetti M, Jasonni V. Appendicectomy for simple appendicitis: video-assisted or intracorporeal?.  J Laparoendosc Adv Surg Tech A. 2007;  17 478-482
• 16 Moehrlen U, Schwöbel F, Reichmann E. et al . Early peritoneal macrophage function after laparoscopic surgery compared with laparotomy in a mouse model.  Surg Endosc. 2005;  19 958-963
• 17 Neuhaus SJ, Watson DI. Pneumoperitoneum and peritoneal surface changes.  A review. Surg Endosc. 2004;  18 1316-1322
• 18 Oka T, Kurkchubasche AG, Bussey JG. Open and laparoscopic appendectomy are equally safe and acceptable in children.  Surg Endosc. 2004;  18 242-245
• 19 Prystowsky JB, Pugh CM, Nagle AP. Appendicitis.  Curr Probl Surg. 2005;  42 688-742
• 20 R Development Core Team. .R: A language and environment for statistical computing. R Foundation for Statistical Computing. Vienna: Austria ISBN 3-900051-07-0. Available at: http://www.r-project.org Accessed 16 November 2007
• 21 Sacheck J. Pediatric obesity: an inflammatory condition?.  J Parenter Enteral Nutr. 2008;  32 633-637
• 22 Sauerland S, Lefering R, Neugebauer EAM. Laparoscopic versus open surgery for suspected appendicitis.  Cochrane Database Syst Rev. 2004;  4 CD001546
• 23 Serour F, Witzling M, Gorenstein A. Is laparoscopic appendectomy in children associated with an uncommon postoperative complication?.  Surg Endosc. 2005;  19 919-922
• 24 Shimotakahara A, Kuebler JF, Vieten G. et al . Carbon dioxide directly suppresses spontaneous migration, chemotaxis, and free radical production of human neutrophils.  Surg Endosc. 2008;  22 1813-1817
• 25 Springer TA. Adhesion receptors of the immune system.  Nature. 1990;  346 425-434
• 26 Tsuji M, Puri P, Reen DJ. Characterisation of the local inflammatory response in appendicitis.  J Pediatr Gastroenterol Nutr. 1993;  16 43-48
• 27 Ure BM, Niewoid TA, Bax NMA. et al . Peritoneal, systemic, and distant organ inflammatory responses are reduced by a laparoscopic approach and carbon dioxide vs air.  Surg Endosc. 2002;  16 836-842
• 28 Venables WN, Ripley BD. Modern Applied Statistics with S-PLUS. 3rd ed. New York: Springer-Verlag 1999 pp. 285-289
• 29 Volz J, Koster S, Spacek Z. Characteristic alterations of the peritoneum after carbon dioxide pneumoperitoneum.  Surg Endosc. 1999;  13 611-614
• 30 Wilks SS. The large-sample distribution of the likelihood ratio for testing composite hypotheses.  Annals of Mathematical Statistics. 1938;  9 60-62
• 31 Zeillemaker AM, Hoynck van-Papendrecht AA, Hart, D. Peritoneal interleukin-8 in acute appendicitis.  J Surg Res. 1996;  62 273-277

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