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Management of perforated appendicitis in children: a decade of aggressive treatment
1Department of Surgery, Children's Hospital, Boston, MA 02115.
Insights
This study evaluated a treatment algorithm for perforated appendicitis in children, including immediate surgery and antibiotics. The established protocol demonstrated a low complication rate, establishing it as a "gold standard" for perforated appendicitis treatment.
Area of Science:
- Pediatric Surgery
- Infectious Diseases
- Gastrointestinal Surgery
Background:
- Perforated appendicitis in children is linked to high morbidity.
- Established treatment algorithms aim to minimize complications.
Purpose of the Study:
- To evaluate the long-term efficacy of a specific treatment algorithm for perforated appendicitis in pediatric patients.
- To establish a benchmark for complication rates in perforated appendicitis management.
Main Methods:
- Retrospective analysis of 373 pediatric patients treated between 1981 and 1991.
- Standardized treatment included immediate appendectomy, antibiotic irrigation, transperitoneal drainage, and a 10-day intravenous antibiotic course (ampicillin, clindamycin, gentamicin).
Main Results:
- A major complication rate of 6.4% was observed in 373 patients.
- Infectious complications occurred in 4.8%, including intraabdominal abscesses (1.3%) and wound infections (1.3%).
- No deaths were reported; the average length of stay was 11.4 days.
Conclusions:
- The described treatment plan achieved the lowest reported complication rate for perforated appendicitis to date.
- This protocol is considered the "gold standard" for managing perforated appendicitis in children.
- Alternative treatments must demonstrate equal or lower complication rates to be considered viable.
Abstract:
Perforated appendicitis in children continues to be associated with significant morbidity. In 1976, a treatment algorithm was begun at the authors' institution, which included immediate appendectomy, antibiotic irrigation of the peritoneal cavity, transperitoneal drainage through the wound, and 10-day treatment with intravenous ampicillin, clindamycin, and gentamicin. Initial results with this scheme in 143 patients demonstrated a 7.7% incidence of major complications and no deaths. From 1981 through 1991, the authors continued to use this treatment plan in all patients with perforated appendicitis. Three hundred seventy-three patients with perforated appendicitis were treated, and the rate of major complications was 6.4%. Infectious complications occurred in 18 patients (4.8%) and included intraabdominal abscesses (5 patients, 1.3%), phlegmon treated with an extended course of antibiotics (6 patients, 1.6%), wound infections (5 patients, 1.3%), and enterocutaneous fistula requiring further operations (2 patients, 0.5%). There were six cases of small bowel obstruction (1.6%), which required operative intervention. There were no deaths. The average length of stay for all patients was 11.4 days (range, 8 to 66 days). Utilization of transperitoneal drainage and choice of antibiotic therapy continue to be sources of controversy in the surgical literature. However, the treatment plan used in the present study resulted in the lowest complication rate reported to date, and the authors conclude that this scheme is truly the "gold standard" for treatment of perforated appendicitis. New treatment plans using laparoscopic appendectomy, different or shorter courses of antibiotics, or not using drains should have complication rates that are as low as, or lower than this one to be considered as useful alternatives.