Perforated appendicitis in children: risk factors for the development of complications

The Risk of Adhesive Bowel Obstruction in Children With Appendicitis: A Systematic Review

OBJECTIVE

Complicated appendicitis is associated with a higher risk of postoperative complications, including adhesive bowel obstruction. The aim of this meta-analysis is to investigate the difference in rates of postoperative bowel obstruction in paediatric patients with complicated versus simple appendicitis and whether this is influenced by the surgical approach.

METHODS

A systematic literature search following PRISMA guidelines was conducted using MEDLINE, Embase and Cochrane Library for studies that analysed incidence of adhesive bowel obstruction in paediatric patients after appendicectomy. Studies from 1998 to 2022 were included in analysis. The study protocol was registered on PROSPERO (ID CRD42022309769).

RESULTS

Pooled analysis of 6 studies with low risk of bias and adequate follow up periods, considering 58,962 cases of appendicectomy, revealed complex appendicitis was associated with a near two-fold increase in incidence of SBO (pooled odds ratio 2.02 (95% CI 1.35-2.69)). Interestingly, a similar pooled analysis of 10 studies, considering 62,433 cases of appendicectomy, revealed no significant difference between open and laparoscopic management of complex appendicitis (pooled odds ratio 0.93 (95% CI 0.24 to 1.62)).

CONCLUSION

Complex appendicitis is associated with a two-fold increase in the rates of adhesive bowel obstruction. Whilst there are cosmetic advantages of a laparoscopic approach, surgical expertise should be favoured in decision making relating to surgical approach (laparoscopic versus open) as the evidence for a laparoscopic approach reducing risks of adhesive bowel obstruction is not convincing.

LEVEL OF EVIDENCE

Level II.

Drain placement in paediatric complicated appendicitis: a systematic review and meta-analysis

Children undergoing appendicectomy for complicated appendicitis are at an increased risk of post-operative morbidity. Placement of an intra-peritoneal drain to prevent post-operative complications is controversial. We aimed to assess the efficacy of prophylactic drain placement to prevent complications in children with complicated appendicitis. A systematic review was performed in accordance with PRISMA guidelines. Cochrane, MEDLINE and Web of Science databases were searched from inception to November 2022 for studies directly comparing drain placement to no drain placement in children ≤ 18 years of age undergoing operative treatment of complicated appendicitis. A total of 5108 children with complicated appendicitis were included from 16 studies; 2231 (44%) received a drain. Placement of a drain associated with a significantly increased risk of intra-peritoneal abscess formation (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.16-2.24, p = 0.004) but there was no significant difference in wound infection rate (OR 1.46, 95% CI 0.74-2.88, p = 0.28). Length of stay was significantly longer in the drain group (mean difference 2.02 days, 95% CI 1.14-2.90, p < 0.001). Although the quality and certainty of the available evidence is low, prophylactic drain placement does not prevent intra-peritoneal abscess following appendicectomy in children with complicated appendicitis.

Variability in the management of adhesive small bowel obstruction in children

BACKGROUND

This study assessed inter-hospital variability in operative-vs-nonoperative management of pediatric adhesive small bowel obstruction (ASBO).

METHODS

A multi-institutional retrospective study was performed examining patients 1-21 years-of-age presenting with ASBO from 2010 to 2019 utilizing the Pediatric Health Information System. Multivariable mixed-effects logistic regression was performed assessing inter-hospital variability in operative-vs-nonoperative management of ASBO.

RESULTS

Among 6410 pediatric ASBO admissions identified at 46 hospitals, 3,239 (50.5%) underwent surgery during that admission. The hospital-specific rate of surgery ranged from 35.3% (95%CI: 28.5-42.6%) to 74.7% (66.3-81.6%) in the unadjusted model (p < 0.001), and from 35.1% (26.3-45.1%) to 73.9% (66.7-79.9%) in the adjusted model (p < 0.001). Factors associated with operative management for ASBO included admission to a surgical service (OR 2.8 [95%CI: 2.4-3.2], p < 0.001), congenital intestinal and/or rotational anomaly (OR 2.5 [2.1-3.1], p < 0.001), diagnostic workup including advanced abdominal imaging (OR 1.7 [1.5-1.9], p < 0.001), non-emergent admission status (OR 1.5 [1.3-1.8], p < 0.001), and increasing number of complex chronic comorbidities (OR 1.3 [1.2-1.4], p < 0.001). Factors associated with nonoperative management for ASBO included increased hospital-specific annual ASBO volume (OR 0.98 [95%CI: 0.97-0.99], p = 0.002), older age (OR 0.97 [0.96-0.98], p < 0.001), public insurance (OR 0.87 [0.78-0.96], p = 0.008), and presence of coinciding non-intestinal congenital anomalies, neurologic/neuromuscular disease, and/or medical technology dependence (OR 0.57 [95%CI: 0.47-0.68], p < 0.001).

CONCLUSIONS

Rates of surgical intervention for ASBO vary significantly across tertiary children's hospitals in the United States. The variability was independent of patient and hospital characteristics and is likely due to practice variation.

LEVEL OF EVIDENCE

III.

Predictive Value of Neutrophil Count for Postoperative Complications in Children after Surgery of Perforated Appendicitis

Introduction: Perforated appendicitis (PA) in children is associated with a considerable risk for postoperative complications (POCs) such as wound infection and intra-abdominal abscess.

The aim of this study was to determine the diagnostic accuracy of hematological parameters in the early POC detection in children after PA surgery.

Materials and Methods: The study enrolled 71 patients with PA divided into two groups: 14 patients with POC (POC+ group) and 57 patients without POC (POC− group). Clinical and hematological parameters were followed preoperatively, prior to the surgery (PRO) and postoperatively on day 2 (POD2) and day 4 (POD4).

Results: The POC+ group had longer duration of higher axillar temperature as well as extended intensive and inpatient care. This group also had a significantly lower absolute neutrophil count ratio between POD2 and POD4. According to the receiver operating characteristic curve analysis, relative neutrophil count on POD4 higher than 71.8% and the ratio of absolute neutrophil count between POD2 and POD4 lower than 44.5% were found to be useful for predicting POC.

Conclusion: Absolute neutrophil count ratio between POD2 and POD4 and relative neutrophil count at POD4 could be efficient in identifying children at higher risk of developing POC after PA surgery.

Non-Operative Management is More Cost-Effective than Immediate Operation in Perforated Appendicitis Patients with Seven or More Days of Symptoms

BACKGROUND

Management of perforated appendicitis in children remains controversial. Nonoperative (NO) and immediate operative (IO) strategies are used with varying outcomes. We hypothesized that IO intervention for patients with perforated appendicitis would be more cost-effective than NO management.

METHODS

A retrospective chart review of all patients with appendicitis from 2012 to 2015 was performed. Patients with perforated appendicitis were defined by evidence of perforation on imaging. We excluded patients who presented with sepsis, organ failure, and ventriculoperitoneal shunts. NO management was determined by surgeon preference. Univariate and multivariate analyses were performed.

RESULTS

IO was performed on 145 patients with perforated appendicitis, whereas 83 were treated with NO management. Compared to IO patients, NO patients incurred higher overall costs, greater length of stay, more readmissions, complications, peripherally inserted central venous catheter lines, interventional radiology drains, and unplanned clinic and emergency department visits (P < 0.0001 for all). Multivariate analysis adjusting for age, days of symptoms, admission C-reactive protein and white blood cell count revealed that NO management was independently associated with increased costs (OR 1.35, 1.12-1.62, 95% CI). Cost curves demonstrated that total cost for IO surpasses that of NO management when patients present with greater than 6.3 d of symptoms (P = 0.01).

CONCLUSIONS

Our data suggest that IO is more cost-effective than NO management for patients with perforated appendicitis who present with less than 6.3 d of symptoms, after which point, NO management is more cost-effective.

LEVEL OF EVIDENCE

IV.

Comparative Effectiveness of Ceftriaxone plus Metronidazole versus Anti-Pseudomonal Antibiotics for Perforated Appendicitis in Children

Background: Appendicitis is the most common pediatric surgical emergency and one of the most common indications for antibiotic use in hospitalized children. The antibiotic choice differs widely across children's hospitals, and the optimal regimen for perforated appendicitis remains unclear. Methods: We conducted a retrospective cohort study comparing initial antibiotic regimens for perforated appendicitis at a large tertiary-care children's hospital. Children hospitalized between January 2011 and March 2015 who underwent surgery for perforated appendicitis were identified by ICD-9 codes with confirmation by chart review. Patients were excluded if they had been admitted ≥48 hours prior to diagnosis, had a history of appendicitis, received inotropic agents, were immunocompromised, or were given an antibiotic regimen other than ceftriaxone plus metronidazole (CTX/MTZ) or an anti-pseudomonal drug (cefepime, piperacillin/tazobactam, ciprofloxacin, imipenem, or meropenem) within the first two days after diagnosis. The primary outcome of interest was post-operative complications, defined as development of an incisional infection or abscess within six weeks of hospital discharge. Results: Of the 353 children who met the inclusion criteria, 252 (71%) received CTX/MTZ and the others received an anti-pseudomonal regimen. A post-operative complication occurred in 37 (14.7%) of the CTX/MTZ group versus 18 (17.8%) of the anti-pseudomonal group. Antibiotic-related complications occurred in 4.4% of children on CTX/MTZ and 6.9% of children on anti-pseudomonal antibiotics (p = 0.32). In a multivariable logistic regression model adjusting for sex, age, ethnicity, and duration of symptoms prior to presentation, the adjusted odds ratio for post-operative complications in children receiving anti-pseudomonal antibiotics was 1.25 (95% confidence interval 0.66-2.40). Conclusion: Post-operative complication rates did not differ for children treated with CTX/MTZ versus a broader-spectrum regimen.

The efficacy of combined therapy with metronidazole and broad-spectrum antibiotics on postoperative outcomes for pediatric patients with perforated appendicitis

The aim of this study was to evaluate the efficacy of combined therapy with metronidazole and broad-spectrum antibiotics for patients with perforated appendicitis who underwent surgical intervention.Broad-spectrum antibiotic therapy is warranted in the treatment of perforated appendicitis. Metronidazole has been used as anaerobic antimicrobial therapy. However, few studies about the use of metronidazole in perforated appendicitis have been reported.The medical records of 249 patients treated with metronidazole combined with broad-spectrum antibiotics following perforated appendicitis surgery were reviewed retrospectively and compared with the medical records of 149 patients treated only with broad-spectrum antibiotics. Propensity score matching was performed to adjust for selected baseline variables. Clinical outcomes, including postoperative complications and length of hospital stay, were compared between the 2 groups.No differences were found between the use of combined therapy with metronidazole and the use of solely broad-spectrum antibiotic agents with regard to postoperative duration of intravenous antibiotic treatment (6.8 ± 1.3 vs 7.9 ± 2.1 days, respectively, P = .18), inflammation variables at POD 5 (white blood cell [WBC] [risk ratio [RR], 1.06; 95% confidence interval [CI], 0.67-1.93, P = .15] and C-reactive protein [CRP] [RR, 1.18; 95% CI, 0.73-2.25, P = .36]) (Table 2), and the mean postoperative length of hospital stay (LOS) (RR, 0.68, 95% CI, 0.41-0.94, P = .41). There were also no differences in the incidence of postoperative complications, including the intra-abdominal or pelvic abscess rate (7[7.1%] vs 9[9.2%], respectively, P = .40), the incidence of wound infection (14[14.3%] vs 15[15.3%], respectively, P = .50), and the 30-day readmission rate (9[9.2%] vs 12[12.2%], respectively, P = .32).Regarding overall postoperative outcomes and complications, our study demonstrated no beneficial clinical effects of metronidazole administration in patients with perforated appendicitis who underwent surgical intervention. Therefore, metronidazole is not indicated when broad-spectrum antibiotics such as aminopenicillins with β-lactam inhibitors or carbapenems and select cephalosporins are used.

Risk factors for the development of complicated appendicitis in adults

OBJECTIVE

To investigate the patient's history and physical examination information to find out risk factors associated with complicated appendicitis.

MATERIAL AND METHODS

Two hundred patients who were admitted with complicated appendicitis (including abscess, phlegmon, and generalized peritonitis) were retrieved from our database. Two hundred patients with non-complicated acute appendicitis were randomly selected from the same period. These two groups were compared in terms of demographic characteristics, past medical history, and presenting symptoms. We made a multivariate analysis model using binary logistic regression and backward stepwise elimination.

RESULTS

Based on multivariate analysis, risk factors for complicated appendicitis included presenting with epigastric pain (OR=3.44), diarrhea (OR=23.4) or malaise (OR=49.7), history of RLQ pain within the past 6 months (OR=4.93), older age (OR=1.04), being married (OR=2.52), lack of anorexia (OR=4.63) and longer interval between onset of symptoms and admission (OR=1.46). Conversely, higher (academic) education was associated with decreased odds for complicated appendicitis (OR=0.26).

CONCLUSION

Our findings suggest that a surgeon's clinical assessment is more reliable to make a judgment. "Bedside evaluation" is a useful, cheap, quick and readily available method for identifying those at risk for developing complicated acute appendicitis.

Are there reliable indicators predicting post-operative complications in acute appendicitis?

PURPOSE

To clarify the predictors of post-operative complications of pediatric acute appendicitis.

METHODS

The medical records of 485 patients with acute appendicitis operated on between January 2006 and November 2014 were retrospectively reviewed. Age, sex, preoperative WBC, CRP, and appendix maximum short diameter on diagnostic imaging (AMSD) were compared retrospectively with the complications group (Group C) vs the non-complication group (Group NC) by Student's T test, Fisher exact test and Multivariate analysis. Regression analysis with p less than 0.01 was considered significant. We analyzed the most recent 314 laparoscopic appendectomy patients similarly.

RESULTS

Complications were found in 29 of the 485 appendectomies (6.0%). Comparing Group C to Group NC, preoperative WBC (×10(3)/μl) 16.4 ± 5.6 vs 14.1 ± 4.1 (p < 0.01), CRP (mg/dl) 8.3 ± 7.1 vs 3.3 ± 4.6 (p < 0.01), AMSD (mm) was 12.1 ± 3.7 vs 9.9 ± 2.8 (p < 0.01). The CRP was significantly different by Multivariate analysis, but the WBC and AMSD wasn't. The results following laparoscopic appendicectomy data were identical.

CONCLUSION

Preoperative WBC, CPR and AMSD all indicated an increased risk of complications. If WBC (/μl) >16,500, CRP >3.1 mg/dl and AMSD >11.4 mm, complications increased sixfold.

Pediatric surgeon vs general surgeon: does subspecialty training affect the outcome of appendicitis?

BACKGROUND

The absence of pediatric surgeons in many centers results in restriction of patient access to pediatric subspecialty care. The aim of this study was to compare the outcomes of children treated for appendicitis by pediatric surgeons (PS) and by general surgeons (GS).

METHODS

This was a retrospective review of the charts of all consecutive patients <16 years old who underwent appendectomy during 2 years The primary outcome measure was the overall rate of complications. Secondary outcome measures included length of hospital stay (LOS), symptom duration, time from emergency department diagnosis to surgery, and readmission rate within 30 days.

RESULTS

A total of 94 patients (PS group, n = 66; GS group, n = 28) were included. PS patients were younger. For patients with complicated appendicitis, complications were significantly more prevalent in the GS group (57% vs 15%; P = 0.0001). Median LOS was not significantly different between the two groups for complicated appendicitis, but patients with non-complicated appendicitis had a significant longer LOS when treated by PS (3.74 ± 1.5 vs 2.57 ± 1.21 days; P = 0.0041). Patients in the PS group had a prolonged use of antibiotics (2 vs 4 days; P = 0.001), and longer LOS (3 vs 4 days; P = 0.0018).

CONCLUSIONS

Overall complication rates were similar between PS and GS. Complications were significantly more prevalent in patients with complicated appendicitis who were treated by GS.

Appendicitis in children less than 5 years old: influence of age on presentation and outcome

PURPOSE

Appendicitis is the most common emergency surgical condition of the abdomen in children. This study sought to delineate the presentation and the outcome of appendicitis in children younger than 5 years old.

METHODS

A retrospective review was conducted of all children younger than 5 years of age who underwent appendectomy for acute appendicitis over a 12-year period.

RESULTS

One thousand eight hundred thirty-six patients younger than 19 years of age underwent appendectomy. Two hundred eighty-one children with an age range of 6 months to 4.9 years were included in this study. Perforation rates were higher in the younger patients (86% <1 year, 74% 1-1.9 years, 60% 2-2.9 years, 64% 3-3.9 years, and 49% 4-4.9 years), but the youngest children had fewer postoperative abscesses.

CONCLUSIONS

In children less than 5 years old with appendicitis, age has a direct correlation to the stage of disease. The youngest children present with more advanced appendicitis but are less likely to develop postoperative abscesses.

Prevention of infectious complications after laparoscopic appendectomy for complicated acute appendicitis--the role of routine abdominal drainage

PURPOSE

Complicated acute appendicitis is still associated with an increased morbidity. If laparoscopy has been accepted as a valid approach, some questions remain concerning intra-abdominal abscess formation. Routine prophylactic drainage of the abdomen has been proposed. However, this practice remains a matter of debate, poorly validated in the literature. With the present study, we investigated the impact of drainage in laparoscopic appendectomy for complicated appendicitis.

METHOD

This is a case match study of consecutive patients operated on by laparoscopy in a single institution. One hundred and thirty patients operated for complicated appendicitis (local peritonitis without perforation, with perforation, or with periappendicular abscess) with prophylactic intraperitoneal drainage were matched one by one to 130 patients operated without drainage. Uncomplicated appendicitis and generalized peritonitis were excluded. Primary endpoint was surgical complications and secondary endpoints were transit recovery time and length of hospital stay.

RESULTS

Patients without drain had significantly less overall complications (7.7% vs. 18.5%, p = 0.01). Moreover, the absence of drainage was of significant benefit for transit recovery time (2.5 vs. 3.5 days, p = 0.0068) and length of hospital stay (4.2 vs. 7.3 days, p < 0.0001).

CONCLUSION

No benefits were observed for prophylactic drainage of the abdominal cavity during emergency laparoscopic treatment of complicated appendicitis. For this reason, this practice may be abandoned.

An evidence-based definition for perforated appendicitis derived from a prospective randomized trial

PURPOSE

Appendicitis is the most common urgent condition in general surgery, and yet there is no evidence-based definition for perforation. Therefore, all retrospective data published on perforated appendicitis are unreliable because of an ill-defined denominator. For approximately 2 years beginning in April 2005, we performed a prospective randomized trial investigating 2 different antibiotic regimens for perforated appendicitis. During this study, we strictly defined perforation as a hole in the appendix or a fecalith in the abdomen. Before this prospective study, perforation was staff surgeon opinion. We investigated the abscess rates in both the perforated and nonperforated appendicitis populations before and during the study to determine if our definition was safe and that there was not an increased risk of abscess formation in patients treated as nonperforated.

METHODS

Records of all patients undergoing laparoscopic appendectomy for appendicitis during the immediate 2 years before using the definition were compared to those treated in the 2 years after the definition was implemented. Interval and incidental appendectomies were ruled out. The postoperative abscess rate (when perforation was not defined) was compared to the abscess rate of those for whom perforation was strictly defined.

RESULTS

There were 292 patients treated for acute nonperforated appendicitis in the 2 years before the definition and 388 patients after the definition. There were 131 patients treated for perforated appendicitis before the definition and 161 after the definition was implemented. The abscess rate in those with perforated appendicitis increased from 14% to 18% after the definition was used. However, after the definition began to be used, the abscess rate for those patients treated as nonperforated decreased from 1.7% to 0.8%.

CONCLUSIONS

Defining perforation as a hole in the appendix or a fecalith in the abdomen is effective in identifying the patients at risk for postoperative abscess formation. Application of these criteria would allow substantial reduction in therapy for patients with purulent or gangrenous appendicitis who do not possess the same abscess risk. These data outline the first evidence-based definition of perforation.

Image-guided drainage of multiple intraabdominal abscesses in children with perforated appendicitis: an alternative to laparotomy

BACKGROUND

Appendicitis is the most common cause of an acute abdomen in children. With perforation, multiple intraperitoneal collections can be seen at presentation. In this situation, surgical treatment alone is rarely effective.

OBJECTIVE

To determine the role of image-guided drainage in treating patients with acute appendicitis complicated by multiple intraabdominal collections.

MATERIALS AND METHODS

A retrospective review of patient charts and interventional radiology records was performed to identify all patients with acute complicated appendicitis treated by multiple image-guided drainage procedures. Data reviewed included the number of drainages and aspirations performed, drain dwell time, the clinical course and temperature profile, and the length of inpatient hospital stay and any complications experienced.

RESULTS

The study population comprised 42 children with a mean age of 107.6 months. A total of 100 drainage catheters were inserted and 56 aspirations were performed. Of the 42 children, 24 were successfully treated at a single sitting, while 18 returned for further intervention. The mean drain dwell time was 8.18 days. The mean inpatient stay was 15.02 days. Treatment of the acute presentation with image-guided intervention was successful in 92.3% of children.

CONCLUSION

Successful management of acute perforated appendicitis with multiple intraabdominal abscesses can be achieved with multiple minimally invasive image-guided drainage procedures.

Predictive value of white blood cell count and C-reactive protein in children with appendicitis

BACKGROUND/PURPOSE

Few studies have addressed the predictive value of white blood cells (WBCs) and C-reactive protein (CRP) at different cutoff values in appendicitis. Our purpose was to determine the cutoff values for WBC and CRP at different periods during clinical evolution of appendicitis and to establish their use for the diagnosis of appendicitis and differentiation of simple from perforated appendicitis.

METHODS

We studied 198 patients operated on for appendicitis, which were further divided into 4 subgroups according to the time from the onset of symptoms to diagnosis. Receiver operating characteristic curves were constructed for CRP and WBC; the best cutoff points were used to calculate the sensitivity and specificity to discriminate patients with and without appendicitis and patients with simple and perforated appendicitis.

RESULTS

White blood cell and CRP individually and together had a high sensitivity to differentiate patients with and without appendicitis. The specificity of WBC and CRP taken individually and together to differentiate patients with simple and perforated appendicitis was high, but the sensitivity was low.

CONCLUSIONS

White blood cell and CRP could be used to support the clinical diagnosis of appendicitis, and, depending on the time from the onset of symptoms to diagnosis, to differentiate patients with and without appendicitis and discriminate simple from perforated appendicitis.

Current management of appendicitis

Appendicitis is the most common surgical disease of the abdomen in children. Pediatric appendicitis varies considerably in its clinical presentation, contributing to delay in diagnosis and increased morbidity. The methods of diagnosis and treatment of appendicitis also vary significantly among clinicians and medical centers according to the patient's clinical status, the medical center's capabilities, and the physician's experience and technical expertise. Recent trends include the increased use of radiologic imaging, minimally invasive and nonoperative treatments, shorter hospital stays, and home antibiotic therapy. Little consensus exists regarding many aspects of the care of the child with complicated appendicitis. This article examines the most debated aspects of the diagnosis and management of the diseased pediatric appendix.

Persistent elevation of serum interleukin-6 in intraabdominal sepsis identifies those with prolonged length of stay

BACKGROUND/PURPOSE

Elevated serum interleukin-6 (IL-6) levels in patients with intraabdominal sepsis have been associated with increased morbidity and mortality. The authors hypothesized that after surgical intervention a persistent elevation of IL-6 would more accurately reflect the inflammatory state and thus predict the subsequent time to recovery better than the preoperative value alone.

METHODS

Nineteen consecutive children with peritonitis and manifestations of the systemic inflammatory response syndrome were enrolled prospectively. IL-6 levels were determined from pre- and postoperative serum samples (within 12 to 24 hours) by enzyme-linked immunosorbant assay (ELISA). Patient postoperative length of stay (LOS) was recorded.

RESULTS

Before surgery, patient serum IL-6 levels ranged from 48 to 132,546 pg/mL. LOS ranged from 4 to 60 days, with subjects falling into 2 groups of < or =11 (n = 14) and > or =25 (n = 5) days. Using an IL-6 level greater than 500 pg/mL to predict a prolonged LOS (>11 days), a persistent elevation of IL-6 postoperatively appears to increase the likelihood of a prolonged LOS.

CONCLUSIONS

Persistent IL-6 levels greater than 500 pg/mL may be useful in identifying pediatric intraabdominal sepsis patients with prolonged LOS and presumably greater morbidity. Rapid identification of these patients may allow for novel therapeutic interventions.

Pericarditis as complication of appendicitis

Pericarditis as a complication of appendicitis is a rare event. In a 25-year period we encountered two pediatric cases with this severe complication due to (a)typical presentation of appendicitis resulting in small bowel obstruction, intraabdominal abscesses, constrictive pericarditis, and purulent pericarditis.

Treatment strategy when using intraoperative peritoneal lavage for perforated appendicitis in children: a preliminary report

We attempt to quantify the amount of peritoneal irrigation required to significantly decrease the intraperitoneal bacteria in children with perforated appendicitis, as no ideal volume of peritoneal lavage has yet been determined. A series of 11 children who were operated on for peritonitis caused by perforated appendicitis were reviewed retrospectively. All children were treated with our treatment protocol that included intraoperative peritoneal lavage using a large volume of saline. Peritoneal fluid samples were taken before and after peritoneal lavage and then were cultured to determine the colony counts. Twenty of 24 bacteria were available for evaluation of the changes in the flora counts. We found 85% of species to be resistant to peritoneal lavage when 3-5 l of saline per square meter of body surface area (l/m2) were used. In contrast, 5.8+/-1.54 l/m2 of peritoneal lavage fluid was necessary to completely eradicate the intraperitoneal bacterial flora. The residual bacteria showed a greater decrease when lavage fluid in excess of 6 l/m2 was used. Although this is only a preliminary report, these findings could be used to justify a true prospective randomized trial in the future.

Is delayed operative treatment worth the trouble with perforated appendicitis is children?

BACKGROUND

Approximately 30% to 50% of appendicitis in children is already perforated at presentation. The optimal management of these children remains controversial.

METHODS

Ninety-six children (aged 2 to 16 years) were treated for perforated appendicitis. Seventy-one underwent immediate appendectomy and drainage of abscess, if present (group I). In the other 25 an attempt was made to treat with intravenous antibiotics, combined with transrectal (4) or percutaneous (2) drainage of abscess. This treatment was successful in 16 patients (group II), who underwent appendectomy 6 to 8 weeks later, and unsuccessful in 9 patients (group III), who underwent appendectomy 3 to 12 days later.

RESULTS

The mean length of stay was as follows: group I, 6.7 days; group II, 8.9 days; and group III, 10.9 days (not significant). The white blood cell count (WBC) at presentation was group I, 18.6 K; group II, 17.9 K; group III, 18.8 K. The percent fall of WBC on day 4 was group I, 55%; group II, 25.5%; group III, 17% (P >0.05 versus groups I and II). Twenty of 71 patients in group I (28%) developed wound infection (5), pelvic abscess (14), and pancreatitis (1), while 2 of 16 (12.5%) of group II and 1 of 9 (11%) of group III patients required readmission (both P <0.05 versus group I).

CONCLUSIONS

These data show that initial antibiotic treatment of perforated appendicitis in children, followed by interval appendectomy, is useful for a select group who present with little or no peritonitis, slightly elevated temperature, and WBC that falls at least 25% within 3 to 4 days.

Perforated appendicitis in children: is there a best treatment?

PURPOSE

This study was performed to provide outcome data for the development of evidenced-based management techniques for children with appendicitis in the authors' hospital.

METHODS

This is a retrospective analysis of 1,196 consecutive children with appendicitis over a 5-year period (1996 to 2001) at a metropolitan hospital.

RESULTS

The median age was 9 years (7 months to 18 years). The perforation rate was 38.9%, and the nonappendicitis rate was 5.6%. Predictors of perforation included age less than 8 years, Hispanic ethnicity, generalized abdominal tenderness, rebound tenderness, and increased number of bands. In perforated cases, the median length of stay was 5 days, and the complication rate was 13.5%. There was no difference in complication rates related to type or timing of antibiotics or related to the individual surgeon. There was no difference in infection rates related to type of wound management.

CONCLUSIONS

Children with perforated appendicitis are treated effectively by a less expensive broad-spectrum antibiotic regimen, expeditious operation by open or laparoscopic technique, primary wound closure, and postoperative intravenous antibiotics until they are afebrile for 24 hours and have a white blood cell count of less than 12,000/mm3. This approach is to be used in our prospective, randomized analysis of children treated on or off a clinical pathway.

Appendicitis in children: a ten-year update of therapeutic recommendations

BACKGROUND/PURPOSE

In 1990, the authors reported excellent outcomes using a standard protocol to treat pediatric appendicitis. This protocol has been simplified further and a large retrospective review was conducted to assess current outcomes.

METHODS

All patients treated for presumed appendicitis between April 1997 and December 1999 were reviewed. All patients received preoperative gentamicin and clindamycin. Patients with complicated appendicitis received postoperative ampicillin, gentamicin, and clindamycin or metronidazole. All wounds were closed primarily without drains. Patients with complicated appendicitis were discharged when their ileus resolved, they remained afebrile for 24 hours, and had a normal leukocyte count.

RESULTS

A total of 648 patients were reviewed. A total of 9.4% of appendices were pathologically normal, 55.6% were simple acute, 15.7% were gangrenous, and 19.3% were perforated. Hospital stay was 2.21 +/- 2.04 days for normal, 1.39 +/-.89 for simple acute, 2.97 +/- 1.25 for gangrenous, and 6.31 +/- 3.51 days for perforated appendices. There were no wound infections in patients with normal or simple acute appendices. Two minor intraabdominal infections (0.56%) occurred in patients with simple appendicitis. Patients with complicated appendicitis (gangrenous or perforated) had wound infection and intraabdominal infection rates of 2.6% and 4.4%, respectively.

CONCLUSIONS

The authors' current protocol results in reasonable hospital stays and good outcomes. It serves as an evidence-based standard of care for the treatment of pediatric appendicitis.

Specialty versus generalist care of children with appendicitis: an outcome comparison

BACKGROUND/PURPOSE

Some Health Maintenance Organizations (HMO) limit access of their members to specialists to lower costs. The purpose of this study is to determine whether this policy affects the outcome of children with appendicitis.

METHODS

At a large academic medical center, children 17 years or younger with appendicitis were treated either by an HMO Adult General Surgical Service (group A) or a Pediatric Surgical Service (group B). Board certified pediatric surgeons were not available on the HMO surgical service. Anesthesia, surgical residents, nursing, and ancillary support services were identical in both groups. Study parameters included imaging tests performed, operation type, complications, readmissions, and length of stay. Results were analyzed using chi(2) and Fischer's Exact tests.

RESULTS

One-hundred seventy-five consecutive children underwent appendectomy, 96 in group A and 79 in group B. In patients with simple acute appendicitis, there was no significant difference between group A and group B for complications, readmissions, second operation, or length of stay. In patients with gangrenous or perforated appendicitis there was a significant difference between group A and group B for type of operation (laparoscopic appendectomy, group A, 4 of 27 v. group B, 0 of 34; P =.04); complications (group A, 9 of 27 v. group B, 3 of 34; P =.025); readmissions (group A, 6 of 27 v. group B, 0 of 34; P =.001); second operation (group A, 6 of 27 v. group B, 2 of 34; P =.001); and mean total length of stay in days (group A, 8.6 of 27 v. group B, 5.4 of 34; P =.05).

CONCLUSIONS

Children with significantly perforated appendicitis have lower complication rates and shorter lengths of hospital stay when treated by pediatric surgeons as compared with HMO adult general surgeons.

Effect of pediatric surgical practice on the treatment of children with appendicitis

OBJECTIVE

Acute appendicitis in children is managed by both general surgeons (GSs) and pediatric surgeons (PSs). Our objective was to investigate the economics of surgical care provided by either GSs or PSs for appendicitis.

METHODS

The outcome of children within our state who underwent operative treatment for appendicitis (January 1994 to June 1997) by board-certified GSs were compared with the results of PSs. Data were sorted according to patient age and diagnosis according to the International Classification of Diseases, Ninth Revision. Analysis of variance was performed on continuous data, and chi(2) analysis was performed on nominal data; data are depicted as mean +/- standard error of the mean.

RESULTS

GSs (n = 2178) managed older children when compared with PSs (n = 1018; 11.0 +/- 0.1 vs 9.1 +/- 0.1 years) and less frequently treated perforated appendicitis (18.8% vs 31.9%). Independent of diagnosis (simple or perforated appendicitis), younger children (0-4 years, 5-8 years, and 9-12 years) who were treated by PSs had a significantly shorter hospital stay and/or decreased hospital charge when compared with those who were treated by GSs. However, older children (13-15 years) seemed to have comparable outcomes.

CONCLUSIONS

Younger children with appendicitis have reduced hospital days and charges when they are treated by PSs.

Acute appendicitis in children: emergency department diagnosis and management

Early diagnosis of appendicitis in infants and children can prevent perforation, abscess formation, and postoperative complications, and can decrease cost by shortening hospitalizations. This article reviews the epidemiology, physiology, and age-specific clinical presentation of childhood appendicitis. The accuracy of diagnostic adjuncts is reviewed, as are strategies for avoiding misdiagnosis and improving emergency department evaluation and management.

Intraabdominal pressure: a parameter helpful for diagnosing and predicting a complicated course in children with appendicitis

BACKGROUND/PURPOSE

The intraabdominal pressure (IAP) of children presenting with acute, perforated, or suspected appendicitis were determined and compared to define if the IAP has any diagnostic value or helps to predict a complicated course.

METHODS

Eighty-four patients with a initial diagnosis of appendicitis were evaluated. In addition to preoperative measurements, IAP of each patient was determined repeatedly on the postoperative first, second, and third days. The patients were grouped according to the final diagnoses as acute, perforated, or suspected appendicitis or negative exploration. The preoperative and postoperative IAP of the patients were compared among the groups. Postoperative complications were recorded, and IAP of those patients were additionally compared with the others in the same group.

RESULTS

Whereas a normal appendix was found in 4 of the operated patients, 27 and 38 patients had acute and perforated appendicitis, respectively. The mean preoperative values of IAP for acute, perforated, or suspected appendicitis and negative exploration were 6.2 +/- 0.4, 9 +/- 0.3, 0.3 +/- 0.4, and 3 +/- 0.4 cm H2O, respectively (P< .001). Postoperative first day and second day values of the IAP for acute appendicitis, perforated appendicitis, and negative laparotomy groups were 2 +/- 0.2 and 0.6 +/- 0.1,3 +/- 0.1 and 1.5 +/- 0.1,0.5 +/- 0.6 and -0.2 +/- 0.6 cm H2O, respectively. The difference between acute and perforated appendicitis groups was significant (P< .05). Wound infection was encountered in 7 among 38 patients with perforated appendicitis. The preoperative and first postoperative day IAP values of patients with perforated appendicitis who experienced a wound infection and who were without a wound infection have been 11.8 +/- 0.4 and 4.8 +/- 0.2, and 8.4 +/- 0.2 and 3.1 +/- 0.3 cm H2O (P< .001). Discriminant analysis has shown that 93.3%, 70.4%, and 73.3% of patients with suspected, acute, and perforated appendicitis have been within the expected groups. IAP less than 1.39 cm H2O has excluded appendicitis with a 95% confidence interval. Although the interval has been between 5.40 and 7.04 cm H2O for acute appendicitis, it has varied between 8.46 and 9.70 cm H2O for perforated appendicitis.

CONCLUSIONS

Although the IAP does not increase in conditions mimicking appendicitis, it increases among children with appendicitis. A further increase is encountered among children with perforated appendicitis. Complicated course is encountered among children with highest IAP values. Therefore, IAP may be used both as a diagnostic parameter and a predictor of a complicated course associated with appendicitis in children.

The impact of intraoperative culture on treatment and outcome in children with perforated appendicitis

BACKGROUND

Most protocols for the operative treatment of perforated appendicitis use a routine culture. Although isolated studies suggest that routine culture may not be necessary, these recommendations generally are not based on objective outcome data.

METHODS

The authors reviewed the records of 308 children who underwent operative treatment for perforated appendicitis between 1988 and 1998 to determine if information gained from routine culture changes the management or improves outcome. Inclusion criteria included either gross or microscopic evidence of appendiceal perforation.

RESULTS

Mean patient age was 7.5 years, 51% were boys, and there was no mortality. The majority of children (96%) underwent culture that was positive for either aerobes (21%), anaerobes (19%), or both (57%). Antibiotics were changed in only 16% of the patients in response to culture results. The use of empiric antibiotics, as compared with modified antibiotics, was associated with a lower incidence of infectious complication, shorter fever duration, and decreased length of hospitalization. We also investigated the relationship between culture isolates and antibiotic regimens with regard to outcome. The utilization of antibiotics suitable for the respective culture isolate or organism sensitivity was associated with an increased incidence of infectious complication and longer duration of both fever and length of hospitalization. Finally, the initial culture correlated poorly with subsequent intraabdominal culture (positive predictive value, 11%).

CONCLUSION

These outcome data strongly suggest that the practice of obtaining routine cultures can be abandoned, and empiric broad spectrum antibiotic coverage directed at likely organisms is completely adequate for treatment of perforated appendicitis in children.