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The avoidable excesses in the management of perforated appendicitis in children
Insights
This study shows that a streamlined treatment for perforated appendicitis in children, involving prompt surgery and antibiotics, achieved the lowest complication rates. This approach avoided unnecessary procedures like transperitoneal drainage.
Area of Science:
- Pediatric Surgery
- Infectious Diseases
Background:
- Perforated appendicitis in children presents significant management challenges.
- Previous treatments often involved invasive procedures and higher complication rates.
Purpose of the Study:
- To evaluate a simplified management strategy for perforated appendicitis in pediatric patients.
- To compare complication rates between different treatment approaches.
Main Methods:
- Retrospective analysis of 100 children with perforated appendicitis managed between 1979-1985.
- Group A: 88 children with peritonitis treated with antibiotics and early appendectomy.
- Group B: 12 children with a periappendiceal mass treated nonoperatively with interval appendectomy.
Main Results:
- Group A had a 6.8% complication rate, including wound infections and abscesses.
- Group B had a 16.7% complication rate, including small bowel obstruction and recurrent abscess.
- The study's approach yielded complication rates comparable to the lowest reported in literature.
Conclusions:
- A management strategy focusing on timely surgery and appropriate antibiotics can minimize morbidity in perforated appendicitis.
- This approach avoids excessive treatments like transperitoneal drainage and antibiotic lavage.
- Subcuticular wound closure offers excellent cosmetic outcomes with minimal care.
Abstract:
During a five-year period from 1979 to 1985, 100 consecutive children with perforated appendicitis were managed at our institution. These patients were divided into two groups, which were determined by length of illness and physical findings. Group A consisted of 88 children with signs and symptoms of peritonitis from appendiceal perforation. They were treated with fluid resuscitation, antipyretics, and triple antibiotics (ampicillin, gentamicin, clindamycin), and appendectomy within a few hours of hospitalization. Saline lavage was used. Group B was composed of 12 patients with a periappendiceal mass without generalized peritonitis who had symptoms of 6 to 12 days duration. They were treated nonoperatively with triple antibiotics and underwent interval appendectomy 4 to 6 weeks later. The complication rate for Group A was 6.8%. This included three wound infections (3.4%), one intra-abdominal abscess (1.1%), one patient with pneumonia and ileus (1.1%), and a small bowel obstruction (1.1%). These results are equivalent to the lowest complication rate reported in the literature, in which the treatment included transperitoneal drainage, antibiotic lavage, and parenteral antibiotics. Group B patients had a 16.7% complication rate, which included one small bowel obstruction and one recurrent intra-abdominal abscess. Our method of management resulted in the lowest complication rate reported to date in children with perforated appendicitis. Transperitoneal drainage, delayed wound closure, and antibiotic lavage were not used. Subcuticular incisional closure resulted in minimal wound care and excellent cosmetic results. The experience demonstrates that with proper timing of surgery and appropriate use of contemporary antibiotics, the morbidity of perforated appendicitis can be limited and excesses of treatment can be avoided.