Open appendectomy for pediatric ruptured appendicitis: a historical clinical review of the prophylaxis of wound infection and postoperative intra-abdominal abscess

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.

ANTIBIOTICS FOR APPENDICECTOMY IN CHILDREN AND ADOLESCENTS DURING THE PERIOPERATIVE PERIOD: AN INTEGRATIVE REVIEW

ABSTRACT Objective: To analyze the preoperative use of antibiotics in children and adolescents requiring appendectomy. Data source: Integrative review was performed in the MEDLINE, Latin American and Caribbean Health Sciences (LILACS) and Cochrane databases and the PubMed portal, with no time limit. The keywords used were: appendicitis, child, adolescent and antibacterial with Boolean AND. The articles included were published in Portuguese, English or Spanish and whose participants were under 18 years of age. Review articles and guidelines were excluded. The studies were classified according to their level of evidence and 24 papers were selected. Data collection and analysis: Seven randomized clinical trial studies (level of evidence II), eight cohorts (level III), seven retrospective observational studies (level V) and two historical documentary analysis (level IV) were selected. The studies addressed antibiotics used in acute appendicitis in both uncomplicated and complicated cases. Antibiotics initiated in the preoperative period showed a decrease in the rates of surgical wound infections. First-line (empiric) regimens were tested for sensitivity to microorganisms in peritoneal material cultures, however the results were controversial. Broad-spectrum antibiotics have been suggested in some studies because they have good coverage, but in others they have not been recommended because of the risk of developing bacterial resistance. Shorter administration time and earlier change to the oral route reduced hospitalization time. Conclusions: There are several clinical protocols with different antibiotics. However, there is no standardization concerning the type of antibiotic drug, time of use, or route.

Antibiotic Powder Reduces Surgical Site Infections in Children After Single-Incision Laparoscopic Appendectomy for Acute Appendicitis

BACKGROUND

Single-incision laparoscopic appendectomy (SILA) has a higher rate of wound infection than the multiport technique. The purpose of this project was to determine whether the use of topical antibiotic powder reduces surgical site infections (SSIs) in pediatric patients who undergo SILA.

METHODS

Patients aged 0-21 years who underwent SILA for acute appendicitis from April 2015 to November 2016 were included in this quality improvement initiative. Cefoxitin powder was placed in the umbilical wound before skin closure. Data were prospectively collected and outcome measures were compared with a historical cohort who underwent SILA before the implementation of antibiotic powder.

RESULTS

There were 108 patients in the historical group (HIST) and 126 in the powder group (POWD). The groups were similar in age (HIST: 11.5 ± 3.6 versus POWD: 12.2 ± 3.7 years, P = .15) and body mass index percentile (HIST: 57.6 ± 30.7 versus POWD: 58.8 ± 27.8, P = .84). Operative time was longer in the powder group (HIST: 26.5 ± 7.5 versus POWD: 29.7 ± 8.9 minutes, P = .004). Length of stay (HIST: 0.2 ± 0.4 versus POWD: 0.1 ± 0.4 days, P = .06), 30-day return to emergency department (HIST: 7% versus POWD: 8%, P = 1.0), and hospital readmissions (HIST: 5% versus POWD: 2%, P = .8) were similar. There was a significantly lower rate of superficial SSIs in the powder group (HIST: 4.6% versus POWD: 0%, P = .02).

CONCLUSIONS

In pediatric patients undergoing SILA for acute appendicitis, the use of cefoxitin powder in the umbilical wound is a simple intervention to reduce the incidence of superficial SSIs.

Pre-operative CT predictors associated with 30-day adverse events in patients with appendiceal inflammatory masses who underwent immediate appendectomies

PURPOSE

To retrospectively evaluate pre-operative CT predictors that are associated with 30-day adverse events in patients who underwent immediate appendectomies for appendiceal inflammatory masses.

METHODS

This retrospective study was approved by our institutional review board, and the requirement for informed consent was waived. One hundred forty-four consecutive patients who underwent immediate appendectomies and were diagnosed with appendiceal inflammatory masses by pre-operative CT from January 2005 to December 2013 at a tertiary hospital were included. The main outcome measure was 30-day adverse events. Patient demographics and data for inflammatory markers including leukocyte counts, segmented neutrophils, and C-reactive protein levels were collected by a single radiologist. Pre- and post-operative CT findings were evaluated for features of appendiceal inflammatory masses, associated findings, and post-operative adverse events by two radiologists in a blinded fashion with consensus to assess surgical and pathologic results, post-operative outcomes, and original CT interpretations. Appendiceal inflammatory masses were defined as complicated appendicitis with a phlegmon or an abscess that was identified on pre-operative CT exam. Factors associated with 30-day adverse events were assessed using logistic regression analysis.

RESULTS

A total of 22 (15%) of the 144 patients (mean age [±SD] 44.6 ± 22.0 years, range 3-97 years) experienced 30-day adverse events: ten intra-abdominal abscesses, three wound infections, two cases of peritonitis, two small bowel obstructions, two intra-abdominal abscesses with peritonitis, one intra-abdominal abscess with wound infection, one intra-abdominal abscess with small bowel obstruction, and one case of peritonitis with small bowel obstruction. In univariate analysis, the presence of appendicolith (odds ratio [OR] 2.49, p = 0.048) and high-grade obstruction (OR 3.79; p = 0.01) were associated with adverse events. High-grade obstruction (adjusted OR 3.05; p = 0.04) was the only independent pre-operative predictor associated with 30-day adverse events in patients with appendiceal inflammatory masses.

CONCLUSIONS

High-grade obstruction was an independent pre-operative CT predictor associated with 30-day adverse events in patients who underwent immediate appendectomies for appendiceal inflammatory masses.

New strategy during complicated open appendectomy: Convert open operation to laparoscopy

AIM: To introduce a new strategy during complicated open appendectomy - converting open operation to laparoscopy.

METHODS: We retrospectively reviewed databases at two institutions between October 2010 and January 2013, identifying 826 patients who had undergone complicated appendectomy for histologically confirmed acute or chronic appendicitis. They included 214 complicated appendectomies: 155 lengthened-incision open appendectomies (LIA group) and 59 open appendectomies with conversion to laparoscopy (OACL group).

RESULTS: A total of 214 patients with complicated appendectomies were included in the study, including 155 cases of LIA and 59 cases of OACL. No major complication leading to death occurred in the study. Patient characteristics of the two groups were similar. Several parameters showed a significant difference between the two groups. For the OACL vs LIA groups they were, respectively: incision length (3.8 ± 1.4 cm vs 6.2 ± 3.5 cm, P < 0.05); time to flatus recovery (2.3 ± 0.6 d vs 4.2 ± 0.8 d, P < 0.05), drainage rate (61.0% vs 80.0%, P < 0.05); pain level (3.6 ± 1.8 vs 7.2 ± 2.4, P < 0.05); hospital stay (5.1 ± 2.7 d vs 8.7 ± 3.2 d, P < 0.05); complication rate (8.5% vs 14.7%, P < 0.05). Other factors showed no significant differences.

CONCLUSION: Lengthened-incision open appendectomy increases the incidence of complications and prolongs the hospital stay. Conversion of open to laparoscopic appendectomy is feasible and efficient in complicated cases. It decreases the rate of incisional and abdominal infections, allows faster return of bowel movements, and shortens the hospital stay.

Different urinalysis appearances in children with simple and perforated appendicitis

PURPOSE

This study aimed to determine whether routine urinalysis may serve as a tool in discriminating between acute appendicitis and perforated appendicitis in children.

BASIC PROCEDURES

We prospectively collected 357 patients with clinically suspected acute appendicitis. Urinalysis was performed in patients with clinically suspected acute appendicitis before surgical intervention. Routine urinalysis is composed of 2 examinations: chemical tests for abnormal chemical constituents and microscopic tests for abnormal insoluble constituents. Receiver operating characteristic curves for urine white blood cell (WBC) counts and urine red blood cell (RBC) counts in distinguishing between patients with simple appendicitis and patients with perforated appendicitis were also analyzed.

MAIN FINDINGS

Urine ketone bodies, leukocyte esterase, specific gravity, pH, WBC, and RBC counts were all significant parameters among patients with normal appendices, simple appendicitis, and perforated appendicitis (all P < .05). Based on multivariate logistic regression analysis, positive urine ketone bodies and nitrate were significant parameters in predicting perforated appendicitis (P = .002 and P = .008, respectively). According to the results of receiver operating characteristic curves, the appropriate cutoff values were 2.0/high-power field for urine RBC counts and 4.0/high-power field for urine WBC counts in predicting perforated appendicitis in children.

PRINCIPAL CONCLUSIONS

Routine urinalysis may serve to aid in discriminating between simple and perforated appendicitis. Clinically, we believe that these urine parameters may aid primary emergency physicians with decision making in patients with clinically suspected appendicitis.