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Management of perforated appendicitis in children--revisited
Insights
A study on pediatric perforated appendicitis found that aggressive fluid resuscitation, antibiotics, peritoneal lavage, and delayed wound closure significantly reduced complications. This protocol, avoiding drains, resulted in zero mortality and fewer abscesses compared to drained cases.
Area of Science:
- Pediatric Surgery
- Infectious Diseases
- Gastrointestinal Surgery
Background:
- Appendiceal perforation with peritonitis is a serious condition in children.
- Previous treatment protocols varied, with concerns about complication rates.
Purpose of the Study:
- To evaluate the efficacy of a specific management protocol for pediatric perforated appendicitis.
- To compare complication rates between drained and undrained surgical approaches.
Main Methods:
- Retrospective analysis of 522 children with acute appendicitis from 1978-1985.
- 170 children had perforated appendicitis treated with aggressive fluid resuscitation, triple antibiotic therapy, peritoneal lavage, delayed wound closure, and no drains (except for localized abscesses).
- Comparison with a smaller group of 24 patients who underwent drainage.
Main Results:
- Minor complication rate was 22% (e.g., wound infection, atelectasis).
- Major complication rate was 3% (e.g., intra-abdominal abscess, pneumonia).
- Zero mortality; only 1.8% developed intra-abdominal abscesses compared to 12.5% in the drained group.
Conclusions:
- The implemented protocol for pediatric perforated appendicitis, emphasizing fluid resuscitation, antibiotics, peritoneal lavage, and delayed closure without routine drainage, is highly effective.
- This approach significantly minimizes serious complications, including intra-abdominal abscess formation, and achieves zero mortality.
- The findings support the avoidance of transperitoneal drains in managing pediatric perforated appendicitis to reduce morbidity.
Abstract:
Of 522 children with acute appendicitis treated from 1978 to 1985, 170 had appendiceal perforation with peritonitis. The protocol for perforation included aggressive fluid resuscitation, preoperative triple antibiotic therapy, copious peritoneal lavage, avoidance of transperitoneal drains except those used for well-localized abscesses, delayed wound closure, and postoperative antibiotic therapy for seven to ten days. The minor complication rate was 22%; this included pleural effusion, wound infection, atelectasis, and prolonged ileus. The major complication rate was 3%; this included intra-abdominal abscess, gastrointestinal bleeding, wound dehiscence, pneumonia, and intestinal obstruction. Only four postoperative intra-abdominal abscesses occurred, in three patients. The mortality rate was zero. A comparison of this series with a similar group of 24 patients who underwent drainage showed the relative rate of abdominal abscess formation to be 1.8% (undrained) vs 12.5% (drained). We achieved our lowest rate of serious complications following surgery for pediatric perforated appendix with the use of aggressive fluid resuscitation, broad-spectrum antibiotic therapy, copious peritoneal irrigation, and delayed wound closure and without drainage.