Primary wound closure after perforated appendicitis in children

Laparoscopic appendectomy is recommended for the treatment of complicated appendicitis in children

Laparoscopic appendectomy in children is well accepted for the treatment of non complicated appendicitis. An increased risk of postoperative intraabdominal abcess formation has been reported in complicated appendicitis. The puropose of this study was to compare open (OA) versus laparoscopic appendectomies (LA) in complicated appendicitis in children and to assess the safety and feasibility of LA. The hospital records of 118 consecutive patients who underwent appendectomy for complicated appendicitis (perforated/gangrenous) from 2000 to 2006 were retrospectively analysed. Fifty-four patients had LA and 64 underwent OA. There were 74 males and 44 females. The length of hospital stay ranged from 4 to 12 days in the LA group and 4 to 17 days in the OA group. Five patients (9.2%) in the LA group had post operative complications; intraabdominal collections in 3 and wound infections in 2. Ten patients (15.6%) had postoperative complications in the OA group; intraabdominal collections in 5, wound infection in 3, pleural effusion in 1 and prolonged ileus in 1. In complicated appendicitis the complication rate is lower for LA as compared to OA. We recommend laparoscopic approach to all children presenting with complicated appendicitis.

What are the True Advantages of a Pediatric Appendicitis Clinical Pathway?

Multiple protocols have been described for pediatric appendicitis, but few have been compared with off-protocol treatment. We performed such a comparison. Children treated for appendicitis by three pediatric surgeons over a 28-month period were studied. A protocol of primary wound closure without drains, standardized use of antibiotics, and patient discharge according to predetermined clinical criteria was compared with individualized drain use, antibiotic selection, and discharge timing. Three hundred ninety-seven children were treated, 43 per cent on pathway (Group I) and 57 per cent off pathway (Group II). The two groups showed similar incidence of acute (45% vs 46%), complicated (50% vs 49%), and normal (5%) appendix. Among patients with simple appendicitis, Group I had less postoperative antibiotic use (16% vs 80% P < 0.001), shorter hospital stays (1.44 vs 1.89 days, P = 0.001), and decreased hospital charges ($9,289 vs $10,751, P = 0.001). Among patients with complicated appendicitis, Group I had less drain placement (4% vs 27%, P < 0.001), less use of discharge antibiotics (13% vs 39%, P < 0.001), and no readmission (0% vs 5%, P = 0.05). Infectious complications were similar between the two groups. A clinical pathway decreases the use of unnecessary antibiotics, hospital stay, and charges for simple appendicitis. It decreases the use of unnecessary drains, and eliminates readmissions after complicated appendicitis.

Laparoscopic appendectomy for perforated appendicitis: a comparison with open appendectomy

BACKGROUND

The role of laparoscopic appendectomy for perforated appendicitis remains controversial. This study aimed to compare laparoscopic and open appendectomy outcomes for children with perforated appendicitis.

METHODS

Over a 36-month period, 111 children with perforated appendicitis were analyzed in a retrospective review. These children were treated with either laparoscopic (n = 59) or open appendectomy. The primary outcome measures were operative time, length of hospital stay, time to adequate oral intake, wound infection, intraabdominal abscess formation, and bowel obstruction.

RESULTS

The demographic data, presenting symptoms, preoperative laboratory values, and operative times (laparoscopic group, 61 +/- 3 min; open group, 57 +/- 3 were similar for the two groups (p = 0.3). The time to adequate oral intake was 104 +/- 7 h for the laparoscopic group and 127 +/- 12 h for the open group (p = 0.08). The hospitalization time was 189 +/- 14 h for the laparoscopic group, as compared with 210 +/- 15 h for the open group (p = 0.3). The wound infection rate was 6.8% for the laparoscopic group and 23% for the open group (p < 0.05). The wounds of another 29% of the patients were left open at the time of surgery. The postoperative intraabdominal abscess formation rate was 13.6% for the laparoscopic group and 15.4% for the open group. One patient in each group experienced bowel obstruction.

CONCLUSIONS

Laparoscopic appendectomy for the children with perforated appendicitis in this study was associated with a significant decrease in the rate of wound infection. Furthermore, on the average, the children who underwent laparoscopic appendectomy tolerated enteral feedings and were discharged from the hospital approximately 24 h earlier than those who had open appendectomy.

Is mini-laparoscopic appendectomy feasible for children

Mini-laparoscopic appendectomy (mini-LA) can be performed safely and efficiently. It is the first treatment choice for patients with acute, uncomplicated appendicitis in our hospital. To evaluate the feasibility of mini-LA for simple and ruptured appendicitis in children, we retrospectively compared the outcomes between mini-LA and open appendectomy for appendicitis in children. From October 1998 to August 2000, the medical records of 585 patients with appendicitis were retrospectively reviewed. Children were defined as patients younger than 15 years of age. The percentage of mini-LA, operation time, time to first flatus passage, duration of hospital stay, and demand for intra-muscular pethidine injection were compared between the mini-LA and open appendectomy. The complications among simple and ruptured appendicitis and the cost of mini-LA and open appendectomy were also analyzed. The operation was performed with one infra-umbilical 10-mm incision, and pneumoperitoneum was established at 12 to 15 mm Hg. A 2-mm laparoscope was inserted via the supra-pubic port, and another 2-mm working port was set-up between the other two ports. Statistical testing using the Whitney-Mann U test and Fisher exact test was performed as appropriate. Of the 585 patients, there were 100 children. The youngest patient was 4 years of age and only 7 patients were younger than 5 years. Among children, 18% had a perforated appendix. Mini-LA accounted for 83% of appendectomies in the pediatric group, but it increased yearly (from 41.7% in 1998 to 92.5% in 2000). The operation time of mini-LA and open appendectomy were 57.32 minutes and 49.12 minutes. There was significant improvement in mini-LA from 1998 to 1999. Flatus passage, hospital stay, and pethidine use all favored the mini-LA. For pediatric appendicitis involving a ruptured appendix, postoperative ileus and length of hospital stay were significantly shortened in the mini-LA group. The postoperative complication was not significantly different between mini-LA and open appendicitis. Mini-LA can be safely performed in pediatric patients and it provides early postoperative recovery and short hospital stay. Even for a ruptured appendix, the mini-LA can be the treatment of choice in a well-equipped hospital with well-trained surgeons.

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.

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.

Active observation of children with possible appendicitis does not increase morbidity

BACKGROUND

Attempts to maximise diagnostic accuracy and reduce unnecessary surgery have led to the hospital observation of children with suspected appendicitis but unconvincing physical signs. However, morbidity associated with perforation necessitates the prompt management of acute appendicitis and increases anxiety concerning prolonged preoperative observation.

METHODS

To assess the preoperative delay and subsequent complications associated with active observation of appendicitis, we reviewed the records of 378 children who had an appendicectomy performed at the Women's and Children's Hospital during a 4-year period.

RESULTS

Active observation was associated with an overall diagnostic accuracy of 93%. The mean preoperative hospital time was 12 h. The incidence of gangrene or perforation was 32%, with a mean preoperative hospital time in this group of 7 h. In view of the short preoperative waiting time in this group, we do not believe perforation in hospital to have been a frequent occurrence. The overall incidence of postoperative infective complications was 4%, with an incidence of 12% following perforation.

CONCLUSIONS

Children with advanced disease often have convincing signs on presentation and are not usually subjected to a significant delay. Active observation is not associated with high postoperative morbidity.

Gangrenous and perforated appendicitis: a meta-analytic study of 2532 patients indicates that the incision should be closed primarily

BACKGROUND

Surgical incisions after appendectomy for complicated (gangrenous or perforated) acute appendicitis are often managed with delayed closure (DC) rather than primary closure (PC). This study synthesizes the results of other studies in the surgical literature and supports the routine use of PC.

METHODS

Studies dealing with complicated appendicitis were reviewed to assess the results of PC in comparison with DC. The rate of incision (wound) infection in groups of patients managed by PC and DC were compared with the use of a statistical technique that defined the probability of expected results by incorporating data derived from all of the various study groups.

RESULTS

Of the 2532 patients who had been treated for complicated appendicitis and who were assessed, 1724 patients underwent PC and 808 patients underwent DC. The rate of incision infection was 4.7% and 4.6% in the PC and DC groups, respectively. With a 95% confidence interval, there was no demonstrable difference between the 2 types of operative site management (P < .01).

CONCLUSIONS

PC of the skin and subcutaneous tissue after appendectomy for gangrenous or perforated appendicitis, combined with the use of antibiotic therapy in the perioperative period, is not associated with an increased risk of incision infection when compared with DC.