Appendicitis in Children: Current Therapeutic Recommendations By I.R. Neilson,
J.-M. Laberge,
L.T. Nguyen,
C. Moir, D. Doody, R.E. Sonnino, Montreal,
0 Wound infection is the most common source of morbidity in appendicitis. Most recent pediatric series use protocols of preoperative antibiotics with aerobic and anaerobic coverage, intraoperative lavage, no peritoneal or wound drains, and continuation of antibiotics postoperatively with complicated appendicitis. There still remains controversy concerning skin closure and the duration of antibiotic therapy. We report the results of a prospective protocol followed over 2 years with 420 children. The protocol was designed to determine whether the skin could be closed primarily in all patients undergoing appendectomy. Preoperatively all patients received triple antibiotics (ampicillin, gentamicin, and clindamycin) that were continued postoperatively for two doses if there was a normal appendix or simple acute appendicitis, for at least 3 days with gangrenous appendicitis, and at least 5 days with perforated appendicitis. Antibiotics were continued if the patient remained febrile or had a white count greater than 10,000. No drains were used and the skin was closed primarily. The overall infectious complication rate was 1.0% (4/420). Among those with a normal appendix or simple acute appendicitis there were no infectious complications. Among those with gangrenous or perforated appendicitis there were 1.7% wound infections (2/l 17) and 1.7% intraabdominal abscesses (2/l 17). Duration of hospitalization was 2.1 days (range, 1 to 5 days) after simple acute appendicitis and 6.9 days (range, 3 to 40 days) after gangrenous or perforated appendicitis. These results set new standards in terms of wound management, infectious complications, and length of hospital stay. 0 1990
by W.B.
INDEX wound
WORDS: infection,
Saunders
Company.
Appendicitis, antibiotics.
primary
wound
closure,
W
OUND INFECTION remains the most common source of morbidity of appendectomy. Many of the previous controversies of management of appendicitis have been resolved. Most recent series use protocols of early appendectomy, preoperative antibiotics with aerobic and anaerobic coverage, measures to minimize operative contamination and peritoneal lavage with or without antibiotics, avoidance of peritoneal or wound drains except for localized abscess, and continuation of antibiotics postoperatively for complicated appendicitis. Controversy still remains over primary skin closure.’ Especially in children, delayed skin closure has important cosmetic and psychological morbidity and results in increased duration and cost of hospitalization. We report the results of a prospective protocol followed in 420 children over a 2-year period at a single institution. The protocol was designed to determine whether the skin could be closed in all patients with simple and complicated appendicitis. Journal
of Pediatric
Surgery,
Vol 25,
No 11 (NovemberI,
1990:
pp 1113-l
S. Youssef,
and F.M. Guttman
Quebec
MATERIALS AND METHODS The records of all patients undergoing emergency appendectomy between December 1986 and December 1988 were reviewed. The protocol followed was standardized for all patients and rigidly followed by all surgeons. Preoperatively, all patients scheduled for appendectomy received triple antibiotics that were continued for two doses in cases of a normal or simple acute appendicitis, at least 3 days for gangrenous appendicitis, and at least 5 days for perforated appendicitis. The antibiotics were ampicillin, 200 mg/kg/d in four doses, gentamicin, 5 mg/kg/d in three doses, and clindamycin, 40 mg/kg/d in four doses. The gentamicin level was not routinely monitored unless the clinical response was unsatisfactory or if the patient required a prolonged antibiotic course. Operative technique was standardized for all surgeons. Skin preparation was with 10% proviodine solution. A right lower quadrant transverse incision was used. No skin or wound barriers were used. The appendix was removed in all cases and any adherent omentum was also resected. The appendiceal stump was usually left without inversion. Peritoneal fluid or pus was obtained for culture in cases of complicated appendicitis. In cases of diffuse peritonitis, copious normal saline lavage was used in all quadrants until the return was clear. No peritoneal or wound drains were used. The wound was irrigated with saline and the skin was closed in all patients with running subcuticular absorbable or nonabsorbable suture. Antibiotics were stopped after the temperature had been normal for 24 hours and if the white blood count was below 10,000. Patients were discharged without further observation after antibiotics were discontinued. Data were collected for 420 patients. Seven additional patients were not included because of omission of preoperative and postoperative antibiotics (2), placement of a peritoneal drain with a localized abscess found at the time of appendectomy (l), and antibiotic therapy with subsequent interval appendectomy (4). None of the excluded patients developed an infectious complication. Follow-up was in the surgery clinic within 7 to 14 days of discharge (97% of patients). Peritoneal cultures and pathology were reviewed. Wound infection was defined according to Ljungqvist’ as discharge of pus or positive culture from the wound. Hence, a “stitch” abscess remote from the incision (1 patient) or erythema that did not progress to suppuration (1 patient) were excluded. Wound infections were assessedby the surgeon in the clinic. Data from infectious complications, classification of appendicitis, and correlation with pathological findings were obtained from a chart review of all patients. RESULTS
Emergency appendectomy was performed in 420 patients over the 2-year period in which the protocol From the Department of Pediatric Surgery. The Montreal Children’s Hospital, and McGill University, Montreal, Quebec. Presented at the 21st Annual Meeting of the Canadian Association of Paediatric Surgeons, Edmonton, Alberta, September 20-23. 1989. Address reprint requests to L.T. Nguyen, MD. Department of Pediatric Surgery, The Montreal Children’s Hospital, 2300 Tupper St, Montreal, Quebec H3H I P3, Canada. o 1990 by W.B. Saunders Company. 0022-3468/90/2511-0002%03.00/0 116
1113
NEILSON
1114
was prospectively followed. The age range was from 1 to 18 years with mean of 10.3 years. Half of the patients were less than 10 years old, whereas 9.2% (39/420) were less than 4 years of age, with a perforation rate of 54% (21/39) in the latter group. There were 19 Inuit (Canadian Eskimo) children transferred from remote locations, 47% of whom (9/ 19) were perforated (Table 1). Of the 420 patients, 380 had appendicitis with a the pathological diagnosis of simple acute appendicitis in 69% (263/380), gangrenous in 7.1% (27/380), and perforated in 23.7% (90/380). Of the patients with perforated appendicitis, 16 had a localized abscess, none of whom were treated with a peritoneal drain. In six patients, the clinical diagnosis was simple acute appendicitis, whereas pathological examination showed microperforation. These patients received only two postoperative doses of antibiotics with no infectious complications. Misdiagnosis of appendicitis occurred in 9.5% (40/ 420) of patients (Table 2). In 18 there was another pathological diagnosis accounting for the clinical presentation. This was evident at laparotomy in 12 patients with ovarian cysts (4), pelvic inflammatory disease (5), nonspecific enteritis (1), perforated Meckel’s diverticulitis (l), and nephroblastoma (1). However, the pathological diagnosis was unsuspected in six and was later recognized by laboratory tests to be Salmonella enteritis (l), verotoxic Escherichia coli 0145 enteritis (I), primary peritonitis (I), Enterobius vermicularis (pinworms in 2), and polyarteritis nodosa (1). There was no associated pathology in 22 patients, three of whom had a fecolith with a histologically normal appendix. None of the 40 patients without appendicitis developed a wound infection. The overall infectious complication rate was 1.0% (4/420). Among those with a normal appendix or simple acute appendicitis there were no infectious complications. Among those with complicated appendicitis (gangrenous and perforated) there were 1.7% wound infections (2/l 17) and 1.7% intraabdominal abscesses (2/ 117). There were no reported adverse effects of antibiotics except occasional minor rashes. There were no other immediate or early postoperative complications. There was no mortality in this series. Duration of hospitalization was a mean of 2.5 days Table
1.
Influence of Age and Patient Characteristics Complications of Appendicitis Acute
Total Age < 4 yr lnuit (Eskimo)
on
Perforation
Total
40 2
263 13
27 2
90 21
420 39
1
7
3
9
20
Table
2.
ET AL
Misdiagnosis of Appendicitis in 40 of 420 Patients Undergoing Appendectomy
No other associated Normal appendix Fecolith Associated
pathology
pathology
Ovarian cyst Salpingitis Enteritis
22 19 3 18 4 5
Salmonella Ecoli0157 ? Crohn’s Pinworms Meckels’s
2 diverticulitis
Nephroblastoma Polyarteritis nodosa Primary peritonitis
1
(range, 1 to 14 days) after removing a normal appendix, 2.1 days (range, 1 to 5 days) after simple acute appendicitis, 3.7 days (range, 3 to 5 days) after gangrenous appendicitis, and 7.8 days (range, 5 to 40 days) after perforated appendicitis. The average stay for all complicated cases (gangrenous and perforated) was only 6.9 days (Table 1). DISCUSSION
At the turn of the century, Ochsner3 presented 565 cases of appendicitis with a mortality rate of 55.5% for 18 patients with diffuse peritonitis, 5% for 197 patients with gangrenous or perforated appendicitis, and 0.33% for 368 patients with simple acute appendicitis. Stone et al4 reported in 197 1 that the rate of intraabdominal abscesses in children after perforated appendicitis could be decreased from 20.9% to 8.7% with the use of antibiotics. Furthermore, the risk of intraabdominal abscess was reported to be 20 times greater when anaerobic bacteria were isolated.4 In 1974, Shandling et al5 reported a 34.7% complication rate with 18.7% wound infections after perforated appendicitis among 550 children, only 35% of whom received antibiotics. A later report from this same institution showed a decrease in wound infection from 50% to 6% with the use of triple antibiotics in children with localized perforation or generalized peritonitis.6 Recent series of complicated appendicitis in children (Table 3) report rates of wound infections between 0% and 3.4% and intraabdominal abscessesbetween 1.1% and 1.8%.‘-” Many of the past controversies in management have been resolved. Antibiotics with anaerobic coverage are definitely beneficial with complicated appendicitis and should be started preoperatively.4*6 Wound drainage is no longer thought to be beneficial; rather, it increases the risk of infection.6 Peritoneal drains are reserved for the occasional retrocecal abscess that can not be debrided properly. It is generally accepted that the free
THERAPY
FOR APPENDICITIS
IN CHILDREN
Table
3.
Review
1115
of Pediatric
Series
of Gangrenous
and Perforated
Appendicitis
Protocol Study David”
No. of Patients
Age W
Triple*
86
8.9
Yes
Schwartz’ Karp*
143t W
9.0 9.0
Yes Yi?S
MacKella? Samelson’”
139 170t
? 9.1
W Yes
Elmore” Present
102 117
7 10.2
Yes Yes
series
*Triple antibiotics: ampicillin, gentamicin, and clindamycin. SAntibiotics metronidazole and (cefamandole or ampicillin 58.3% tSaries
LsVsge 7
Infectious Complications Drain
Skin
Hospital (d)
Wound
+
Closed
12
8.3-15.4s
4.9
2 None
Closed Closed
12.1 11
1.4 3.4
2.8 1.1
Saline Saline
None None
Closed Open
? 11.8
1.4 2.4
1.4 1.8
Saline Saline
None None
Open Closed
8 6.9
0 1.7
1.3 1.7
Cephalothin Saline
(%)
lntraabdominal
and gentamicin).
with preoperative and postoperative antibiotics and 15.4% included cases of perforated appendicitis exclusively.
with only postoperative
peritoneal cavity cannot be drained.’ Intraoperative irrigation of the peritoneal cavity is a valuable adjunct in perforated appendicitis.7q8 Finally, it recently has been shown that once patients meet criteria for discontinuing antibiotics, further observation in hospital in unwarranted and costly.” Current controversies in the management of complicated appendicitis include whether the wound should be left open, whether irrigation fluid should contain antibiotics, and the optimal duration of antibiotic therapy. In simple acute appendicitis, controversy also concerns whether any antibiotic prophylaxis is required. The present series attempts to answer some of these current controversies. A wound infection rate of 1.7% in 1 17 cases of complicated appendicitis shows that there is currently no reason for delayed closure of the appendectomy incision. The principle of delayed closure of contaminated wounds after appendectomy was first introduced by Wilkie13 in 1931. This was a direct application of measures taken during the First World War to lessen the morbidity and mortality of traumatic wounds. Janik and Firor14 reported a decrease in wound infections after apendectomy in children from 3 1.9% to 7.1% when wound closure was delayed rather than primary. The skin was left open with delayed closure after complicated appendicitis in two of six of the most recent pediatric series.10s” Krukowski et al’ state that delayed closure in adults continues to be popular with North American surgeons but not with most British surgeons. With measures to limit peritoneal contamination and with broad-spectrum antibiotics, we feel that primary closure in children can be accomplished in all cases of appendicitis. Skin closure encourages early mobilization and avoids psychologically traumatic and painful dressing changes in young patients. Should a wound infection develop, the incision is easily opened on the ward or in the clinic. Although delayed closure of the wound on the third to fifth postoperative day allows an acceptable cosmetic
antibiotics,
result, it is often inferior to what can be achieved with subcuticular closure. Leaving the wound open requires more nursing care, necessitates delayed closure, and will increase the duration and cost of hospitalization. Despite emphasis on early appendectomy to avoid perforation, the average perforation rate quoted in a recent review of collected series was 28%.i5 Appendiceal perforation determines the degree of operative contamination of the wound, which is one of the most important factors influencing the risk of wound infection. Other factors influencing peritoneal contamination are lack of adequate operative exposure and poor technique, as well as the type of bacterial flora present. Measures to decrease contamination include peritoneal lavage and removal of fecoliths, necrotic omenturn, and fibrin. Whether local as well as systemic antibiotics will increase local tissue antibiotic levels and result in less infectious complications is still not clear.’ However, in several well-designed randomized trials, antibiotic lavage has been shown to be more beneficial than saline lavage. For instance, in a prospective trial of 100 adults, addition of metronidazole and cephazolin to lavage fluid decreased wound sepsis from 34% to 8%~‘~ However, the infection rate of 34% with systemic antibiotics alone is high by today’s standards.’ Among the recent pediatric series, only Schwartz et al7 used antibiotic lavage (cephalothin). It is also not known whether the lavage fluid should include antibiotics with anaerobic coverage. The optimal duration of antibiotic therapy after appendicitis is not known. There is a trend toward a decrease in the duration of antibiotic therapy among subsequent series. Perhaps this is possible because other adjuncts to limit peritoneal contamination have been introduced. Probably, the first preoperative dose of antibiotics is the most important.’ In this series, preoperative antibiotics given to all patients undergoing appendectomy had no adverse effects and provided excellent prophylaxis. Because it is not possible to diagnosis complicated appendicitis preoperatively, we
NEILSON
1116
feel that all patients undergoing appendectomy should receive preoperative antibiotics. Single broad-spectrum antibiotics are also being proposed to replace the triple antibiotic regimen on the grounds of costeffectiveness and toxicity. In conclusion, a protocol of preoperative triple antibiotics, intraoperative lavage, avoidance of drains, and
ET AL
primary skin closure was followed in 420 children undergoing appendectomy. In 117 cases of complicated appendicitis, this protocol and a relatively short course of postoperative antibiotics, as shown by the average hospital stay of only 6.9 days, resulted in only 1.7% wound infections (2/ 117) and 1.7% intraabdominal abscesses (2/l 17).
REFERENCES 1. Krukowski ZH, Irwin ST, Denholm S, et al: Preventing wound infection after appendicectomy: A review. Br J Surg 75:1023-1033, 1988 2. Ljungqvist V: Wound sepsis after clean operations. Lancet 1:1095-1097, 1965 3. Ochsner AJ: The cause of diffuse peritonitis complicating appendicitis and its prevention. JAMA 36:1747-1754, 1901 4. Stone HH, Kolb LD, Geheber CE: Incidence and significance of intraperitoneal anaerobic bacteria. Ann Surg 181:705-715, 1975 5. Shandling B, Ein SH, Simpson JS, et al: Perforating appendicitis and antibiotics. J Pediatr Surg 9:79-83, 1974 6. David IB, Buck JR, Filler RM: Rational use of antibiotics for perforated appendicitis in childhood. J Pediatr Surg 17:494-500, 1982 7. Schwartz MZ, Tapper D, Solenberger RI: Management of perforated appendicitis in children. Ann Surg 197:407-411, 1983 8. Karp MP, Caldarola VA, Cooney DR, et al: The avoidable excessesin the management of perforated appendicitis in children. J Pediatr Surg 21:508-510,1986
9. MacKellar A, Mackay AJ: Wound and intraperitoneal infection following appendicectomy for perforated or gangrenous appendicitis. Aust N Z J Surg 56:489-491,1986 10. Samelson SL, Reyes HM: Management of perforated appendicitis in children-Revisited. Arch Surg 122:691-696, 1987 11. Elmore, JR, Dibbins AW, Curci MR: The treatment of complicate appendicitis in children. Arch Surg 122:424-427, 1987 12. Birken GA, Schropp KP, Boles ET, et al: Discharge planning for children with perforated appendicitis. J Pediatr Surg 21:592-595, 1986 13. Wilkie DPD: Observations on mortality in acute appendicular disease. Br Med J 1:253-255, 1931 14. Janik JS, Firor HV: Pediatric appendicitis: 20 year study of 1640 children at Cook County (Illinois) Hospital. Arch Surg 114:717-719,1979 15. Berry J, Malt RA: Appendicitis near its centenary. Ann Surg 200:567-575,1984 16. El-Sefi TAM, El-Awady HM, Shehata MI, et al: Systemic plus local metronidazole and cephazolin in complicated appendicitis: A prospective controlled trial. J R Co11Surg Edinb 3413-16, 1989
J.-M. Laberge,
L.T. Nguyen,
C. Moir, D. Doody, R.E. Sonnino, Montreal,
0 Wound infection is the most common source of morbidity in appendicitis. Most recent pediatric series use protocols of preoperative antibiotics with aerobic and anaerobic coverage, intraoperative lavage, no peritoneal or wound drains, and continuation of antibiotics postoperatively with complicated appendicitis. There still remains controversy concerning skin closure and the duration of antibiotic therapy. We report the results of a prospective protocol followed over 2 years with 420 children. The protocol was designed to determine whether the skin could be closed primarily in all patients undergoing appendectomy. Preoperatively all patients received triple antibiotics (ampicillin, gentamicin, and clindamycin) that were continued postoperatively for two doses if there was a normal appendix or simple acute appendicitis, for at least 3 days with gangrenous appendicitis, and at least 5 days with perforated appendicitis. Antibiotics were continued if the patient remained febrile or had a white count greater than 10,000. No drains were used and the skin was closed primarily. The overall infectious complication rate was 1.0% (4/420). Among those with a normal appendix or simple acute appendicitis there were no infectious complications. Among those with gangrenous or perforated appendicitis there were 1.7% wound infections (2/l 17) and 1.7% intraabdominal abscesses (2/l 17). Duration of hospitalization was 2.1 days (range, 1 to 5 days) after simple acute appendicitis and 6.9 days (range, 3 to 40 days) after gangrenous or perforated appendicitis. These results set new standards in terms of wound management, infectious complications, and length of hospital stay. 0 1990
by W.B.
INDEX wound
WORDS: infection,
Saunders
Company.
Appendicitis, antibiotics.
primary
wound
closure,
W
OUND INFECTION remains the most common source of morbidity of appendectomy. Many of the previous controversies of management of appendicitis have been resolved. Most recent series use protocols of early appendectomy, preoperative antibiotics with aerobic and anaerobic coverage, measures to minimize operative contamination and peritoneal lavage with or without antibiotics, avoidance of peritoneal or wound drains except for localized abscess, and continuation of antibiotics postoperatively for complicated appendicitis. Controversy still remains over primary skin closure.’ Especially in children, delayed skin closure has important cosmetic and psychological morbidity and results in increased duration and cost of hospitalization. We report the results of a prospective protocol followed in 420 children over a 2-year period at a single institution. The protocol was designed to determine whether the skin could be closed in all patients with simple and complicated appendicitis. Journal
of Pediatric
Surgery,
Vol 25,
No 11 (NovemberI,
1990:
pp 1113-l
S. Youssef,
and F.M. Guttman
Quebec
MATERIALS AND METHODS The records of all patients undergoing emergency appendectomy between December 1986 and December 1988 were reviewed. The protocol followed was standardized for all patients and rigidly followed by all surgeons. Preoperatively, all patients scheduled for appendectomy received triple antibiotics that were continued for two doses in cases of a normal or simple acute appendicitis, at least 3 days for gangrenous appendicitis, and at least 5 days for perforated appendicitis. The antibiotics were ampicillin, 200 mg/kg/d in four doses, gentamicin, 5 mg/kg/d in three doses, and clindamycin, 40 mg/kg/d in four doses. The gentamicin level was not routinely monitored unless the clinical response was unsatisfactory or if the patient required a prolonged antibiotic course. Operative technique was standardized for all surgeons. Skin preparation was with 10% proviodine solution. A right lower quadrant transverse incision was used. No skin or wound barriers were used. The appendix was removed in all cases and any adherent omentum was also resected. The appendiceal stump was usually left without inversion. Peritoneal fluid or pus was obtained for culture in cases of complicated appendicitis. In cases of diffuse peritonitis, copious normal saline lavage was used in all quadrants until the return was clear. No peritoneal or wound drains were used. The wound was irrigated with saline and the skin was closed in all patients with running subcuticular absorbable or nonabsorbable suture. Antibiotics were stopped after the temperature had been normal for 24 hours and if the white blood count was below 10,000. Patients were discharged without further observation after antibiotics were discontinued. Data were collected for 420 patients. Seven additional patients were not included because of omission of preoperative and postoperative antibiotics (2), placement of a peritoneal drain with a localized abscess found at the time of appendectomy (l), and antibiotic therapy with subsequent interval appendectomy (4). None of the excluded patients developed an infectious complication. Follow-up was in the surgery clinic within 7 to 14 days of discharge (97% of patients). Peritoneal cultures and pathology were reviewed. Wound infection was defined according to Ljungqvist’ as discharge of pus or positive culture from the wound. Hence, a “stitch” abscess remote from the incision (1 patient) or erythema that did not progress to suppuration (1 patient) were excluded. Wound infections were assessedby the surgeon in the clinic. Data from infectious complications, classification of appendicitis, and correlation with pathological findings were obtained from a chart review of all patients. RESULTS
Emergency appendectomy was performed in 420 patients over the 2-year period in which the protocol From the Department of Pediatric Surgery. The Montreal Children’s Hospital, and McGill University, Montreal, Quebec. Presented at the 21st Annual Meeting of the Canadian Association of Paediatric Surgeons, Edmonton, Alberta, September 20-23. 1989. Address reprint requests to L.T. Nguyen, MD. Department of Pediatric Surgery, The Montreal Children’s Hospital, 2300 Tupper St, Montreal, Quebec H3H I P3, Canada. o 1990 by W.B. Saunders Company. 0022-3468/90/2511-0002%03.00/0 116
1113
NEILSON
1114
was prospectively followed. The age range was from 1 to 18 years with mean of 10.3 years. Half of the patients were less than 10 years old, whereas 9.2% (39/420) were less than 4 years of age, with a perforation rate of 54% (21/39) in the latter group. There were 19 Inuit (Canadian Eskimo) children transferred from remote locations, 47% of whom (9/ 19) were perforated (Table 1). Of the 420 patients, 380 had appendicitis with a the pathological diagnosis of simple acute appendicitis in 69% (263/380), gangrenous in 7.1% (27/380), and perforated in 23.7% (90/380). Of the patients with perforated appendicitis, 16 had a localized abscess, none of whom were treated with a peritoneal drain. In six patients, the clinical diagnosis was simple acute appendicitis, whereas pathological examination showed microperforation. These patients received only two postoperative doses of antibiotics with no infectious complications. Misdiagnosis of appendicitis occurred in 9.5% (40/ 420) of patients (Table 2). In 18 there was another pathological diagnosis accounting for the clinical presentation. This was evident at laparotomy in 12 patients with ovarian cysts (4), pelvic inflammatory disease (5), nonspecific enteritis (1), perforated Meckel’s diverticulitis (l), and nephroblastoma (1). However, the pathological diagnosis was unsuspected in six and was later recognized by laboratory tests to be Salmonella enteritis (l), verotoxic Escherichia coli 0145 enteritis (I), primary peritonitis (I), Enterobius vermicularis (pinworms in 2), and polyarteritis nodosa (1). There was no associated pathology in 22 patients, three of whom had a fecolith with a histologically normal appendix. None of the 40 patients without appendicitis developed a wound infection. The overall infectious complication rate was 1.0% (4/420). Among those with a normal appendix or simple acute appendicitis there were no infectious complications. Among those with complicated appendicitis (gangrenous and perforated) there were 1.7% wound infections (2/l 17) and 1.7% intraabdominal abscesses (2/ 117). There were no reported adverse effects of antibiotics except occasional minor rashes. There were no other immediate or early postoperative complications. There was no mortality in this series. Duration of hospitalization was a mean of 2.5 days Table
1.
Influence of Age and Patient Characteristics Complications of Appendicitis Acute
Total Age < 4 yr lnuit (Eskimo)
on
Perforation
Total
40 2
263 13
27 2
90 21
420 39
1
7
3
9
20
Table
2.
ET AL
Misdiagnosis of Appendicitis in 40 of 420 Patients Undergoing Appendectomy
No other associated Normal appendix Fecolith Associated
pathology
pathology
Ovarian cyst Salpingitis Enteritis
22 19 3 18 4 5
Salmonella Ecoli0157 ? Crohn’s Pinworms Meckels’s
2 diverticulitis
Nephroblastoma Polyarteritis nodosa Primary peritonitis
1
(range, 1 to 14 days) after removing a normal appendix, 2.1 days (range, 1 to 5 days) after simple acute appendicitis, 3.7 days (range, 3 to 5 days) after gangrenous appendicitis, and 7.8 days (range, 5 to 40 days) after perforated appendicitis. The average stay for all complicated cases (gangrenous and perforated) was only 6.9 days (Table 1). DISCUSSION
At the turn of the century, Ochsner3 presented 565 cases of appendicitis with a mortality rate of 55.5% for 18 patients with diffuse peritonitis, 5% for 197 patients with gangrenous or perforated appendicitis, and 0.33% for 368 patients with simple acute appendicitis. Stone et al4 reported in 197 1 that the rate of intraabdominal abscesses in children after perforated appendicitis could be decreased from 20.9% to 8.7% with the use of antibiotics. Furthermore, the risk of intraabdominal abscess was reported to be 20 times greater when anaerobic bacteria were isolated.4 In 1974, Shandling et al5 reported a 34.7% complication rate with 18.7% wound infections after perforated appendicitis among 550 children, only 35% of whom received antibiotics. A later report from this same institution showed a decrease in wound infection from 50% to 6% with the use of triple antibiotics in children with localized perforation or generalized peritonitis.6 Recent series of complicated appendicitis in children (Table 3) report rates of wound infections between 0% and 3.4% and intraabdominal abscessesbetween 1.1% and 1.8%.‘-” Many of the past controversies in management have been resolved. Antibiotics with anaerobic coverage are definitely beneficial with complicated appendicitis and should be started preoperatively.4*6 Wound drainage is no longer thought to be beneficial; rather, it increases the risk of infection.6 Peritoneal drains are reserved for the occasional retrocecal abscess that can not be debrided properly. It is generally accepted that the free
THERAPY
FOR APPENDICITIS
IN CHILDREN
Table
3.
Review
1115
of Pediatric
Series
of Gangrenous
and Perforated
Appendicitis
Protocol Study David”
No. of Patients
Age W
Triple*
86
8.9
Yes
Schwartz’ Karp*
143t W
9.0 9.0
Yes Yi?S
MacKella? Samelson’”
139 170t
? 9.1
W Yes
Elmore” Present
102 117
7 10.2
Yes Yes
series
*Triple antibiotics: ampicillin, gentamicin, and clindamycin. SAntibiotics metronidazole and (cefamandole or ampicillin 58.3% tSaries
LsVsge 7
Infectious Complications Drain
Skin
Hospital (d)
Wound
+
Closed
12
8.3-15.4s
4.9
2 None
Closed Closed
12.1 11
1.4 3.4
2.8 1.1
Saline Saline
None None
Closed Open
? 11.8
1.4 2.4
1.4 1.8
Saline Saline
None None
Open Closed
8 6.9
0 1.7
1.3 1.7
Cephalothin Saline
(%)
lntraabdominal
and gentamicin).
with preoperative and postoperative antibiotics and 15.4% included cases of perforated appendicitis exclusively.
with only postoperative
peritoneal cavity cannot be drained.’ Intraoperative irrigation of the peritoneal cavity is a valuable adjunct in perforated appendicitis.7q8 Finally, it recently has been shown that once patients meet criteria for discontinuing antibiotics, further observation in hospital in unwarranted and costly.” Current controversies in the management of complicated appendicitis include whether the wound should be left open, whether irrigation fluid should contain antibiotics, and the optimal duration of antibiotic therapy. In simple acute appendicitis, controversy also concerns whether any antibiotic prophylaxis is required. The present series attempts to answer some of these current controversies. A wound infection rate of 1.7% in 1 17 cases of complicated appendicitis shows that there is currently no reason for delayed closure of the appendectomy incision. The principle of delayed closure of contaminated wounds after appendectomy was first introduced by Wilkie13 in 1931. This was a direct application of measures taken during the First World War to lessen the morbidity and mortality of traumatic wounds. Janik and Firor14 reported a decrease in wound infections after apendectomy in children from 3 1.9% to 7.1% when wound closure was delayed rather than primary. The skin was left open with delayed closure after complicated appendicitis in two of six of the most recent pediatric series.10s” Krukowski et al’ state that delayed closure in adults continues to be popular with North American surgeons but not with most British surgeons. With measures to limit peritoneal contamination and with broad-spectrum antibiotics, we feel that primary closure in children can be accomplished in all cases of appendicitis. Skin closure encourages early mobilization and avoids psychologically traumatic and painful dressing changes in young patients. Should a wound infection develop, the incision is easily opened on the ward or in the clinic. Although delayed closure of the wound on the third to fifth postoperative day allows an acceptable cosmetic
antibiotics,
result, it is often inferior to what can be achieved with subcuticular closure. Leaving the wound open requires more nursing care, necessitates delayed closure, and will increase the duration and cost of hospitalization. Despite emphasis on early appendectomy to avoid perforation, the average perforation rate quoted in a recent review of collected series was 28%.i5 Appendiceal perforation determines the degree of operative contamination of the wound, which is one of the most important factors influencing the risk of wound infection. Other factors influencing peritoneal contamination are lack of adequate operative exposure and poor technique, as well as the type of bacterial flora present. Measures to decrease contamination include peritoneal lavage and removal of fecoliths, necrotic omenturn, and fibrin. Whether local as well as systemic antibiotics will increase local tissue antibiotic levels and result in less infectious complications is still not clear.’ However, in several well-designed randomized trials, antibiotic lavage has been shown to be more beneficial than saline lavage. For instance, in a prospective trial of 100 adults, addition of metronidazole and cephazolin to lavage fluid decreased wound sepsis from 34% to 8%~‘~ However, the infection rate of 34% with systemic antibiotics alone is high by today’s standards.’ Among the recent pediatric series, only Schwartz et al7 used antibiotic lavage (cephalothin). It is also not known whether the lavage fluid should include antibiotics with anaerobic coverage. The optimal duration of antibiotic therapy after appendicitis is not known. There is a trend toward a decrease in the duration of antibiotic therapy among subsequent series. Perhaps this is possible because other adjuncts to limit peritoneal contamination have been introduced. Probably, the first preoperative dose of antibiotics is the most important.’ In this series, preoperative antibiotics given to all patients undergoing appendectomy had no adverse effects and provided excellent prophylaxis. Because it is not possible to diagnosis complicated appendicitis preoperatively, we
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feel that all patients undergoing appendectomy should receive preoperative antibiotics. Single broad-spectrum antibiotics are also being proposed to replace the triple antibiotic regimen on the grounds of costeffectiveness and toxicity. In conclusion, a protocol of preoperative triple antibiotics, intraoperative lavage, avoidance of drains, and
ET AL
primary skin closure was followed in 420 children undergoing appendectomy. In 117 cases of complicated appendicitis, this protocol and a relatively short course of postoperative antibiotics, as shown by the average hospital stay of only 6.9 days, resulted in only 1.7% wound infections (2/ 117) and 1.7% intraabdominal abscesses (2/l 17).
REFERENCES 1. Krukowski ZH, Irwin ST, Denholm S, et al: Preventing wound infection after appendicectomy: A review. Br J Surg 75:1023-1033, 1988 2. Ljungqvist V: Wound sepsis after clean operations. Lancet 1:1095-1097, 1965 3. Ochsner AJ: The cause of diffuse peritonitis complicating appendicitis and its prevention. JAMA 36:1747-1754, 1901 4. Stone HH, Kolb LD, Geheber CE: Incidence and significance of intraperitoneal anaerobic bacteria. Ann Surg 181:705-715, 1975 5. Shandling B, Ein SH, Simpson JS, et al: Perforating appendicitis and antibiotics. J Pediatr Surg 9:79-83, 1974 6. David IB, Buck JR, Filler RM: Rational use of antibiotics for perforated appendicitis in childhood. J Pediatr Surg 17:494-500, 1982 7. Schwartz MZ, Tapper D, Solenberger RI: Management of perforated appendicitis in children. Ann Surg 197:407-411, 1983 8. Karp MP, Caldarola VA, Cooney DR, et al: The avoidable excessesin the management of perforated appendicitis in children. J Pediatr Surg 21:508-510,1986
9. MacKellar A, Mackay AJ: Wound and intraperitoneal infection following appendicectomy for perforated or gangrenous appendicitis. Aust N Z J Surg 56:489-491,1986 10. Samelson SL, Reyes HM: Management of perforated appendicitis in children-Revisited. Arch Surg 122:691-696, 1987 11. Elmore, JR, Dibbins AW, Curci MR: The treatment of complicate appendicitis in children. Arch Surg 122:424-427, 1987 12. Birken GA, Schropp KP, Boles ET, et al: Discharge planning for children with perforated appendicitis. J Pediatr Surg 21:592-595, 1986 13. Wilkie DPD: Observations on mortality in acute appendicular disease. Br Med J 1:253-255, 1931 14. Janik JS, Firor HV: Pediatric appendicitis: 20 year study of 1640 children at Cook County (Illinois) Hospital. Arch Surg 114:717-719,1979 15. Berry J, Malt RA: Appendicitis near its centenary. Ann Surg 200:567-575,1984 16. El-Sefi TAM, El-Awady HM, Shehata MI, et al: Systemic plus local metronidazole and cephazolin in complicated appendicitis: A prospective controlled trial. J R Co11Surg Edinb 3413-16, 1989
