Primary Closure of Contaminated By Cathy Burnweit,
Ron Bilik, and Barry Shandling Toronto, Ontario
0 We studied the clinical course of 506 children consecutively admitted with appendicitis at The Hospital for Sick Children from 1985 to 1969. One hundred eighty-one children (35%). ranging in age from 1 to 17 years, presented with perforation verified by histological examination. Ninety-six of them (53%) had generalized peritonitis, 47 (26%) had localized peritonitis, and 36 (21%) had abscess formation. Usually, triple antibiotics were begun preoperatively if perforation was suspected; otherwise, cefoxitin was started. Triple antibiotics were used postoperatively for 5 to 7 days in almost all children in the perforated group. Neither abdominal nor subcutaneous drainage was routinely used even in cases of intraabdominal abscess. The skin was closed primarily with steri-strips (63%). staples (20%). subcutaneous Dexon (11%). or silk (4%). Postoperative wound infection arose in 20 children (11%). Wound infections were noted from 1 to 14 days postoperatively (mean, 5.9 days). Whereas 9 of these were treated with local therapy only, 11 delayed the child’s discharge or necessitated readmission. No patient suffered major complications from wound infection in that there were no cases of necrotizing fasciitis, reoperation for debridement, sepsis, or death. The intraabdominal abscess rate in this group of 181 children was 6% (n = 11). The low rate of infective complications fully justifies the policy of primary closure in contaminated wounds. This policy eliminates the necessity for painful and time-consuming dressing changes, shortens hospitalization, and obviates the trauma of delayed suturing of wounds in children. Copyright o 1991 by W.B. Saunders Company INDEX
WORDS:
Appendicitis,
perforated.
URGICAL DOGMA has long dictated that contaminated wounds be closed by techniques of delayed primary closure or by secondary intention. These closure methods developed in response to rates of wound infection approaching 40%‘,’ in contaminated wounds. However, such data stem from adult series that predate the knowledge that modern antimicrobial therapy is a major determinant of infective complications. The local wound care required with open wounds is painful and psychologically distressing to all patients, but it can be especially devastating in young children. Avoidance of routine dressing changes and subsequent wound closure is
S
From the Division of General Surgery, Hospital for Sick Children, Toronto, Ontario. Presented at the 22nd Annual Meeting of the Canadian Association of Paediatric Surgeons, St John’s, Newfoundland, August 22-25, 1990. Address reprint requests to Barry Shandling, MD, Staff Surgeon, The Hospital For Sick Children, Division of General Surgery, 555 University Ave, Toronto, Ontario, M5G 1X8, Canada. Copyright o 1991 by U?B. Saunders Company 0022-3468/91/2612-0002$03.00/O 1362
Wounds in Perforated Appendicitis
desirable both cosmetically and pyschologically if the complication rates of primary wound closure are acceptable. Perforated appendicitis is probably the most common surgical condition resulting in grossly contaminated wounds in childhood. At The Hospital for Sick Children in Toronto, we routinely close the skin primarly after appendectomy regardless of the presence of rupture and/or gross, diffise peritoneal soilage. This study was undertaken to determine the rates and morbidity of wound infection in the pediatric population following primary closure in perforated appendix. MATERIALS
AND METHODS
We examined the records of 506 consecutive pediatric patients admitted to the hospital with appendicitis from 1985 to 1989. Hospital course was reviewed for the following items: demographic information, length of symptoms, antibiotics used preoperatively and postoperatively, presence or absence of perforation, operative techniques including skin closure and drainage, duration of hospital stay, peritoneal culture results, and development and treatment of complications. Six surgical staff members oversaw the care of these patients with the help of the housestaff. The children ranged in age from 18 months to 18 years (mean, 10.1 years). Females outnumbered males with ratio of 1.4:1. Three hundred twenty-five patients (65%) presented with nonperforated appendicitis and 181 (35%) with appendicile ruptures. Of children with perforation, 96 (53%) had generalized peritonitis, 47 (26%) had localized peritonitis, and 38 (21%) had frank abscess formation. The diagnosis of perforation was histological; appendiceal gangrene or suppurative peritoneal fluid did not constitute rupture unless confirmed microscopically by the pathologist. Although the attending surgeon dictated the exact antibiotic regimen used for treatment of perforation, several generalizations can be made. Triple antibiotics-ampicillin, gentamycin, and clindamycin or metronidazole-were started if the preoperative diagnosis was perforated appendix. One hundred six (59%) of the 181 children with perforation received this combination preoperatively. Sixty-five children (36%) received cefoxitin preoperatively because perforation was not clinically suspected. Seven children received other antibiotic combinations. When perforation was found at surgery, triple antibiotics usually were used postoperatively regardless of the preoperative antibiotic coverage. Most children received a 5- to 7-day course depending on the clinical situation. One hundred seventy-two children (94%) with perforation received at least 5 days of antibiotic coverage; 9 (6%) received courses of antibiotics shorter than 5 days, usually 0 to 2 days postoperatively. This occurred in cases in which a clinically unsuspected perforation was discovered only on histological sections. Three patients received no preoperative antibiotics, either because the resident omitted the order or because the nurses failed to give the on-call medications prior to surgery. The attending surgeon was responsible for determining operative technique. All patients underwent immediate primary wound closure with the method chosen by the surgeon: steri-strips (63%), ~OurnatofPediatricSurgery,
Vol26,
No 12 (December).
1991: pp 1362-1365
APPENDICITIS-WOUND
CLOSURE
1363
staples (20%), Dexon (ll%), silk (4%), or other suture (2%). Neither abdominal nor subcutaneous drainage was used routinely, even in cases of appendiceal abscess. Peritoneal irrigation was recorded in few patients. At the surgeon’s discretion, abdominal drainage was undertaken in 4 children (2%), only one of whom had intraabdominal abscess. The medical records did not clearly reflect why the other children received drains. Subcutaneous penrose drains were placed in 2 children. Anaerobic and aerobic peritoneal cultures were taken in 134 patients (74%). The physicians and an infection control nurse surveyed for complications in hospitalized children. Doctors reported on outpatient wound problems. For the purposes of this study, wound infection was defined as periincisional cellulitis or seropurulent wound drainage, whether culture-positive or not. RESULTS
Postoperative wound infections arose in 20 (11%) of 181 children with perforated appendicitis. Wound infections were noted 1 to 14 days postoperatively (mean, 5.9 days). Wound infection was not related to the type of skin closure (Table 1) or to the clinical manifestation of perforation (Table 2). In children less than 3 years of age, wound infection rate was 18% (2/l 1 children), whereas 11% of older children had wound infections (P = .4). Of note is that 61% of children less than 3 years of age presented with perforation, whereas 34% of children greater than 3 years had rupture at the time of operation (P < .05). Mean length of hospital stay was 4.3 days for children without perforation and 8.1 days for children with perforation (P < .OOOOl).Children with appendiceal rupture who developed wound infections stayed an average of 2.2 days longer (mean, 10.9 days) than those who had no wound infection (mean, 7.7 days) (P < .00001). Nine (45%) of the 20 children with wound infections were treated as out-patients with local therapy alone. Two required opening of the wound in its entirety. In the rest, spontaneous drainage was felt to have adequately treated the wounds so that formal opening was not required. None of these children received oral antibiotics and all healed their wounds without further complication. Three children (15%) with wound infection were readmitted, 1,3, and 4 days after discharge from the hospital. One was treated with wound opening and 5 days of antibiotics. Another had his wound opened, Table
1. Skin Closure
and Wound No. of Patients
Steri-strips Staples Dexon
114 36 20
Silk Other NOTE.
There
7 4 were
no significant
differences.
Infection
Rate No. of Infections
(%I
10 (9) 4(11) 4 (20) 1 (14) 1 (25)
Table
2. Clinical
Generalized Localized Abscess NOTE.
There
Presentation
peritonitis peritonitis were
no significant
and Wound
Infection
Rate
No. of Patients
No. of Infections 1%)
96
12 (13)
47 38
6 (13) 2 (51
differences
started intravenous antibiotics, and was then discharged on day 2 with oral cefalexin. The third child, a markedly obese boy, was admitted for 4 days of local wound care. Eight children had their hospital discharge delayed because of wound infections. Five of these received only the customary 6 or 7 days of postoperative antibiotics but each remained in the hospital for local wound care. The others received 3 to 5 days of further intravenous antibiotic therapy in addition to vigorous wound care. Three quarters of the children who presented with ruptured appendicitis had peritoneal cultures sent. Fecal flora grew in 116 children, although no organisms grew in 20 cases (15%). In not a single case was antibiotic therapy altered on the basis of the results of these intraoperative cultures. In all patients, wound infections ran a benign course. No child required reoperation for drainage or debridement. There were no cases of systemic sepsis, necrotizing fasciitis, or other synergistic infection. There were no deaths in the series. The intraabdominal abscess rate for children with perforation was 6%. No patient’s course was complicated by both wound infection and intraabdominal abscess. DISCUSSION
Appendicitis continues to garner a large portion of resources on pediatric surgical service. At The Hospital for Sick Children, 137 children presented with appendicitis in 1988. This constitutes approximately 6% of total general surgical operations performed and 8% if outpatients procedures are excluded. In approximately one third of the cases of appendicitis, rupture is noted. The percentage of children presenting with perforation does not appear to be decreasing over the past two decades despite continued parental and physician education. The management of the wound in perforated appendicitis remains controversial. A landmark study of over 23,000 wounds by Cruse and Foord’ demonstrated an infection rate of 38.3% in dirty wounds, a figure corroborated by Hardy.’ These and similar data have led to the doctrine that contaminated wounds must not be closed primarily. This recommendation does not take into account the recent advances in
1364
antibiotic therapy, fluid resuscitation, anesthesia, and nutrition. Although many pediatric surgeons still advocate leaving wounds open,3-6 a significant number’.” routinely perform primary skin closure in complicated appendicitis. For this technique to gain universal support, a low infection rate with minimal morbidity and financial burden must be demonstrated. In the present series, the infection rate was 11%. None of the afflicted 20 patients suffered serious morbidity from a wound infection. No additional invasive procedures-fluoroscopic or operative drainage or debridement-were required, and death, synergistic infection, and sepsis did not occur. The wound infections were uniformly low morbidity complications. The financial repercussions of this wound infection rate are acceptable. In about half of those patients only out-patient, local wound care was required and no antibiotics were administered. Wound infections in the other 11 patients led to a total additional hospitalization of 35 days, including 19 patient-days of antibiotics. The extra care for this 5% of the total cadre of 181 patients represents a cost of approximately $45,500 or $250 per patient. Had delayed primary closure been used, care for the open wound given three daily dressing changes costs approximately $85 a day including nursing time, dressing supplies, and medications. This represents a cost per patient of $240, $320, or $400 in wounds closed 3,4, or 5 days, respectively, after operation. This does not include the cost of the surgeon’s time and of the local anesthetic/suture or steri-strips required for the actual skin closure. A final consideration that should not be ignored is the trauma inflicted on the child who requires multiple procedures. Dressing changes in a young patient, particularly in the toddler, not only are painful but cause significant stress as well to the parents and nurses assigned to the task. Clearcut indications of the benefits of delayed primary closure are lacking in this study and in others.7-9 Janik and Firoz” and Samuelson and Reyes’ report wound infection rates of 7.1% and 2.4%, respectively, in delayed primary closure for childhood appendiceal perforation. In several recent studies, the wound infection rate after primary skin closure has been equivalent to or better than this. Schwartz et al, who reported a 1.4% wound infection rate when the skin was closed in perforated appendicitis, left transincisional peritoneal drains after antibiotic irrigation and used at least 10 days of mandatory hospitalization with 9 days of intravenous antibiotics in all patients.’ The average length of stay
BURNWEIT,
BILIK, AND
SHANDLING
was 12.1 days in their series. Karp et al, whose wound infection rate was 3.4%, used extensive saline lavage and no drains, but their patients were hospitalized for a mean of 11.3 days.’ Although the authors report a slightly increased wound infection rate, the average length of stay was 3 days shorter for all patients in the series and even the group of children with wound infections stayed only a mean of 10.9 days. The shortened hospitalization for the group as a whole most likely resulted from shorter courses of antibiotics. Even if the shorter antibiotic coverage relates to the higher wound complication rate in this series, we feel that the significant savings in hospital resources and the benefits of earlier discharge to most of the patients and their families justify the decreased hospitalization given the benign course of wound infections. Modern antimicrobial therapy that includes anaerobic coverage seems to be a major determinant in the prevention of wound infection and its morbidity in appendicitis.R.‘2s13The benefits of peritoneal drainage and intraoperative abdominal irrigation remain controversial. Some investigators suggest that drains brought through the incision in appendicitis serve largely to allow fluid egress from the wound, which might abet the wound infection rate.14 However, well-controlled studies by Haller et all5 and Greenall et al” showed no significant decrease in the complications of pediatric appendicitis when intraperitoneal drains were used. Stone et al” reports an increased incidence of septic complications resulting from transperitoneal drainage following appendectomy. The data concerning peritoneal irrigation with either saline or antibiotic solutions are conflicting. In a prospective, double-blind study, Sherman et al” saw no decrease in the rate of wound sepsis in childhood appendicitis after antibiotic peritoneal lavage. Fowler,” Smith,*’ and Sleeman et al*’ suggest that septic complications are reduced in peritonitis when antibiotic irrigation is used. Saline lavage, although not shown effective in randomized trials,22,23is widely used. Although it is difficult to compare patient cohorts at different institutions, in both the Schwartz et al’ and Karp et al9 series the wound infection rates for childhood perforated appendicitis were lower than in the present series. Their patients received triple antibiotic coverage, as did those in the present study, but both their patient groups were treated routinely with intraoperative peritoneal lavage; we rarely performed abdominal irrigation in the present patients. Perhaps this difference in operative tech-
APPENDICITIS-WOUND
CLOSURE
nique accounts for the difference in the incidence of wound infection. A final note must be made about the relationship between peritoneal culture results and the treatment of wound infections. Peritoneal cultures, which cost $43 per case, were taken in 136 patients for a total cost of $5,848 in this series. These cultures were not used to make a single therapeutic decision in the
group of children we cared for. When both peritoneal and wound cultures were positive, the infecting organism in the wound had almost always been present in the abdomen. But in all cases, antibiotic manipulation when required was based solely on growth from the wound. These data suggest that routine peritoneal culture is both unnecessary and costly and should be abandoned.
REFERENCES 1. Cruse PJ, Foord R: A five-year prospective study of 23,649 surgical wounds. Arch Surg 107:206-210, 1973 2. Hardy JD: Complications in Surgery and Their Management (ed 4). Philadelphia, PA, Saunders, 1981 3. Elmore JR, Dibbins AW, Curci MR: The treatment of complicated appendicitis in children. Arch Surg 122:424-427, 1987 4. Bennion RS, Thompson JE: Early appendectomy for perforated appendicitis in children should not be abandoned. Surg Gynecol Obstet 165:95-loo,1987 5. Samelson SL, Reyes HM: Management of perforated appendicitis in children-Revisited. Arch Surg 122:691-696, 1987 6. Bower RJ, Bell MJ, Ternberg JL: Controversial aspects of appendicitis management in children. Arch Surg 116:885-887, 1981 7. Schwartz MZ, Tapper D, Solenberger RI: The management of perforated appendicitis in children; the controversy continues. Ann Surg 197:407-411,1983 8. David IB, Buck JR, Filler RM: Rational use of antibiotics for perforated appendicitis in childhood. J Pediatr Surg 17:494-500, 1982 9. Karp MP, Caldarola VA, Cooney DR, et al: The avoidable excesses in the management of perforated appendicitis in children. J Pediatr Surg 21:506-510, 1986 10. Seco JL, Ojeda E, Reguilon C, et al: Combined topical and systemic antibiotic prophylaxis in acute appendicitis. Am J Surg 159:226-230, 1990 11, Janik JS, Firoz HV: Pediatric appendicitis: A 20 year study of 1640 children at Cook County (Ill) Hospital. Arch Surg 114:717719,1979 12. Marchildon MB, Dudgeon DL: Perforated appendicitis: Current experience in a children’s hospital. Ann Surg 185:84-87, 1977 13. Busutil RW, Davidson RK, Fine M, et al: Effect of prophy-
lactic antibiotics in acute non-perforated appendicitis: A prospective randomized, double-blind clinical study. Ann Surg 194:502509,1981 14. Otherson HB, Campbell TW: Programmed treatment of ruptured appendicitis in children. South Med J 67:903-907, 1974 15. Haller JA, Shaker IJ, Donahoo JS, et al: Peritoneal drainage versus non-drainage for generalized peritonitis from ruptured appendicitis in children: A prospective study. Ann Surg 177:595600,1973 16. Greenall MJ, Evans M, Pollack AV: Should you drain a perforated appendix? Br J Surg 65:880-882,1978 17. Stone HH, Hooper CA, Millian WJ: Abdominal drainage following appendectomy and cholecystectomy. Ann Surg 187:606612,1978 18. Sherman JD, Luck SR, Borger JA: Irrigation of the peritoneal cavity for appendicitis in children: A double-blind study. J Pediatr Surg 11:371-374, 1976 19. Fowler R: A contrasted trial of intraperitoneal cephaloridine administration in peritonitis. J Pediatr Surg 10:43-50, 1975 20. Smith ED: Adjuvant therapy of generalized peritonitis with intraperitoneally administered cephalothin. Surg Gynecol Obstet 136:441-443, 1973 21. Sleeman HK, Diggs JW, Hayes DK, et al: Value of antibiotics, coricosteroids and peritoneal lavage in the treatment of experimental peritonitis. Surgery 66:1060-1066, 1969 22. Rosato EF, Orain-Smith JC, Mullis WF, et al: Peritoneal lavage treatment in experimental peritonitis. Ann Surg 175:384387,1972 23. Schumer W, Lee DK, Jones B: Peritoneal lavage in the postoperative therapy of later peritoneal sepsis: Preliminary report. Surgery 55841-845, 1964
Ron Bilik, and Barry Shandling Toronto, Ontario
0 We studied the clinical course of 506 children consecutively admitted with appendicitis at The Hospital for Sick Children from 1985 to 1969. One hundred eighty-one children (35%). ranging in age from 1 to 17 years, presented with perforation verified by histological examination. Ninety-six of them (53%) had generalized peritonitis, 47 (26%) had localized peritonitis, and 36 (21%) had abscess formation. Usually, triple antibiotics were begun preoperatively if perforation was suspected; otherwise, cefoxitin was started. Triple antibiotics were used postoperatively for 5 to 7 days in almost all children in the perforated group. Neither abdominal nor subcutaneous drainage was routinely used even in cases of intraabdominal abscess. The skin was closed primarily with steri-strips (63%). staples (20%). subcutaneous Dexon (11%). or silk (4%). Postoperative wound infection arose in 20 children (11%). Wound infections were noted from 1 to 14 days postoperatively (mean, 5.9 days). Whereas 9 of these were treated with local therapy only, 11 delayed the child’s discharge or necessitated readmission. No patient suffered major complications from wound infection in that there were no cases of necrotizing fasciitis, reoperation for debridement, sepsis, or death. The intraabdominal abscess rate in this group of 181 children was 6% (n = 11). The low rate of infective complications fully justifies the policy of primary closure in contaminated wounds. This policy eliminates the necessity for painful and time-consuming dressing changes, shortens hospitalization, and obviates the trauma of delayed suturing of wounds in children. Copyright o 1991 by W.B. Saunders Company INDEX
WORDS:
Appendicitis,
perforated.
URGICAL DOGMA has long dictated that contaminated wounds be closed by techniques of delayed primary closure or by secondary intention. These closure methods developed in response to rates of wound infection approaching 40%‘,’ in contaminated wounds. However, such data stem from adult series that predate the knowledge that modern antimicrobial therapy is a major determinant of infective complications. The local wound care required with open wounds is painful and psychologically distressing to all patients, but it can be especially devastating in young children. Avoidance of routine dressing changes and subsequent wound closure is
S
From the Division of General Surgery, Hospital for Sick Children, Toronto, Ontario. Presented at the 22nd Annual Meeting of the Canadian Association of Paediatric Surgeons, St John’s, Newfoundland, August 22-25, 1990. Address reprint requests to Barry Shandling, MD, Staff Surgeon, The Hospital For Sick Children, Division of General Surgery, 555 University Ave, Toronto, Ontario, M5G 1X8, Canada. Copyright o 1991 by U?B. Saunders Company 0022-3468/91/2612-0002$03.00/O 1362
Wounds in Perforated Appendicitis
desirable both cosmetically and pyschologically if the complication rates of primary wound closure are acceptable. Perforated appendicitis is probably the most common surgical condition resulting in grossly contaminated wounds in childhood. At The Hospital for Sick Children in Toronto, we routinely close the skin primarly after appendectomy regardless of the presence of rupture and/or gross, diffise peritoneal soilage. This study was undertaken to determine the rates and morbidity of wound infection in the pediatric population following primary closure in perforated appendix. MATERIALS
AND METHODS
We examined the records of 506 consecutive pediatric patients admitted to the hospital with appendicitis from 1985 to 1989. Hospital course was reviewed for the following items: demographic information, length of symptoms, antibiotics used preoperatively and postoperatively, presence or absence of perforation, operative techniques including skin closure and drainage, duration of hospital stay, peritoneal culture results, and development and treatment of complications. Six surgical staff members oversaw the care of these patients with the help of the housestaff. The children ranged in age from 18 months to 18 years (mean, 10.1 years). Females outnumbered males with ratio of 1.4:1. Three hundred twenty-five patients (65%) presented with nonperforated appendicitis and 181 (35%) with appendicile ruptures. Of children with perforation, 96 (53%) had generalized peritonitis, 47 (26%) had localized peritonitis, and 38 (21%) had frank abscess formation. The diagnosis of perforation was histological; appendiceal gangrene or suppurative peritoneal fluid did not constitute rupture unless confirmed microscopically by the pathologist. Although the attending surgeon dictated the exact antibiotic regimen used for treatment of perforation, several generalizations can be made. Triple antibiotics-ampicillin, gentamycin, and clindamycin or metronidazole-were started if the preoperative diagnosis was perforated appendix. One hundred six (59%) of the 181 children with perforation received this combination preoperatively. Sixty-five children (36%) received cefoxitin preoperatively because perforation was not clinically suspected. Seven children received other antibiotic combinations. When perforation was found at surgery, triple antibiotics usually were used postoperatively regardless of the preoperative antibiotic coverage. Most children received a 5- to 7-day course depending on the clinical situation. One hundred seventy-two children (94%) with perforation received at least 5 days of antibiotic coverage; 9 (6%) received courses of antibiotics shorter than 5 days, usually 0 to 2 days postoperatively. This occurred in cases in which a clinically unsuspected perforation was discovered only on histological sections. Three patients received no preoperative antibiotics, either because the resident omitted the order or because the nurses failed to give the on-call medications prior to surgery. The attending surgeon was responsible for determining operative technique. All patients underwent immediate primary wound closure with the method chosen by the surgeon: steri-strips (63%), ~OurnatofPediatricSurgery,
Vol26,
No 12 (December).
1991: pp 1362-1365
APPENDICITIS-WOUND
CLOSURE
1363
staples (20%), Dexon (ll%), silk (4%), or other suture (2%). Neither abdominal nor subcutaneous drainage was used routinely, even in cases of appendiceal abscess. Peritoneal irrigation was recorded in few patients. At the surgeon’s discretion, abdominal drainage was undertaken in 4 children (2%), only one of whom had intraabdominal abscess. The medical records did not clearly reflect why the other children received drains. Subcutaneous penrose drains were placed in 2 children. Anaerobic and aerobic peritoneal cultures were taken in 134 patients (74%). The physicians and an infection control nurse surveyed for complications in hospitalized children. Doctors reported on outpatient wound problems. For the purposes of this study, wound infection was defined as periincisional cellulitis or seropurulent wound drainage, whether culture-positive or not. RESULTS
Postoperative wound infections arose in 20 (11%) of 181 children with perforated appendicitis. Wound infections were noted 1 to 14 days postoperatively (mean, 5.9 days). Wound infection was not related to the type of skin closure (Table 1) or to the clinical manifestation of perforation (Table 2). In children less than 3 years of age, wound infection rate was 18% (2/l 1 children), whereas 11% of older children had wound infections (P = .4). Of note is that 61% of children less than 3 years of age presented with perforation, whereas 34% of children greater than 3 years had rupture at the time of operation (P < .05). Mean length of hospital stay was 4.3 days for children without perforation and 8.1 days for children with perforation (P < .OOOOl).Children with appendiceal rupture who developed wound infections stayed an average of 2.2 days longer (mean, 10.9 days) than those who had no wound infection (mean, 7.7 days) (P < .00001). Nine (45%) of the 20 children with wound infections were treated as out-patients with local therapy alone. Two required opening of the wound in its entirety. In the rest, spontaneous drainage was felt to have adequately treated the wounds so that formal opening was not required. None of these children received oral antibiotics and all healed their wounds without further complication. Three children (15%) with wound infection were readmitted, 1,3, and 4 days after discharge from the hospital. One was treated with wound opening and 5 days of antibiotics. Another had his wound opened, Table
1. Skin Closure
and Wound No. of Patients
Steri-strips Staples Dexon
114 36 20
Silk Other NOTE.
There
7 4 were
no significant
differences.
Infection
Rate No. of Infections
(%I
10 (9) 4(11) 4 (20) 1 (14) 1 (25)
Table
2. Clinical
Generalized Localized Abscess NOTE.
There
Presentation
peritonitis peritonitis were
no significant
and Wound
Infection
Rate
No. of Patients
No. of Infections 1%)
96
12 (13)
47 38
6 (13) 2 (51
differences
started intravenous antibiotics, and was then discharged on day 2 with oral cefalexin. The third child, a markedly obese boy, was admitted for 4 days of local wound care. Eight children had their hospital discharge delayed because of wound infections. Five of these received only the customary 6 or 7 days of postoperative antibiotics but each remained in the hospital for local wound care. The others received 3 to 5 days of further intravenous antibiotic therapy in addition to vigorous wound care. Three quarters of the children who presented with ruptured appendicitis had peritoneal cultures sent. Fecal flora grew in 116 children, although no organisms grew in 20 cases (15%). In not a single case was antibiotic therapy altered on the basis of the results of these intraoperative cultures. In all patients, wound infections ran a benign course. No child required reoperation for drainage or debridement. There were no cases of systemic sepsis, necrotizing fasciitis, or other synergistic infection. There were no deaths in the series. The intraabdominal abscess rate for children with perforation was 6%. No patient’s course was complicated by both wound infection and intraabdominal abscess. DISCUSSION
Appendicitis continues to garner a large portion of resources on pediatric surgical service. At The Hospital for Sick Children, 137 children presented with appendicitis in 1988. This constitutes approximately 6% of total general surgical operations performed and 8% if outpatients procedures are excluded. In approximately one third of the cases of appendicitis, rupture is noted. The percentage of children presenting with perforation does not appear to be decreasing over the past two decades despite continued parental and physician education. The management of the wound in perforated appendicitis remains controversial. A landmark study of over 23,000 wounds by Cruse and Foord’ demonstrated an infection rate of 38.3% in dirty wounds, a figure corroborated by Hardy.’ These and similar data have led to the doctrine that contaminated wounds must not be closed primarily. This recommendation does not take into account the recent advances in
1364
antibiotic therapy, fluid resuscitation, anesthesia, and nutrition. Although many pediatric surgeons still advocate leaving wounds open,3-6 a significant number’.” routinely perform primary skin closure in complicated appendicitis. For this technique to gain universal support, a low infection rate with minimal morbidity and financial burden must be demonstrated. In the present series, the infection rate was 11%. None of the afflicted 20 patients suffered serious morbidity from a wound infection. No additional invasive procedures-fluoroscopic or operative drainage or debridement-were required, and death, synergistic infection, and sepsis did not occur. The wound infections were uniformly low morbidity complications. The financial repercussions of this wound infection rate are acceptable. In about half of those patients only out-patient, local wound care was required and no antibiotics were administered. Wound infections in the other 11 patients led to a total additional hospitalization of 35 days, including 19 patient-days of antibiotics. The extra care for this 5% of the total cadre of 181 patients represents a cost of approximately $45,500 or $250 per patient. Had delayed primary closure been used, care for the open wound given three daily dressing changes costs approximately $85 a day including nursing time, dressing supplies, and medications. This represents a cost per patient of $240, $320, or $400 in wounds closed 3,4, or 5 days, respectively, after operation. This does not include the cost of the surgeon’s time and of the local anesthetic/suture or steri-strips required for the actual skin closure. A final consideration that should not be ignored is the trauma inflicted on the child who requires multiple procedures. Dressing changes in a young patient, particularly in the toddler, not only are painful but cause significant stress as well to the parents and nurses assigned to the task. Clearcut indications of the benefits of delayed primary closure are lacking in this study and in others.7-9 Janik and Firoz” and Samuelson and Reyes’ report wound infection rates of 7.1% and 2.4%, respectively, in delayed primary closure for childhood appendiceal perforation. In several recent studies, the wound infection rate after primary skin closure has been equivalent to or better than this. Schwartz et al, who reported a 1.4% wound infection rate when the skin was closed in perforated appendicitis, left transincisional peritoneal drains after antibiotic irrigation and used at least 10 days of mandatory hospitalization with 9 days of intravenous antibiotics in all patients.’ The average length of stay
BURNWEIT,
BILIK, AND
SHANDLING
was 12.1 days in their series. Karp et al, whose wound infection rate was 3.4%, used extensive saline lavage and no drains, but their patients were hospitalized for a mean of 11.3 days.’ Although the authors report a slightly increased wound infection rate, the average length of stay was 3 days shorter for all patients in the series and even the group of children with wound infections stayed only a mean of 10.9 days. The shortened hospitalization for the group as a whole most likely resulted from shorter courses of antibiotics. Even if the shorter antibiotic coverage relates to the higher wound complication rate in this series, we feel that the significant savings in hospital resources and the benefits of earlier discharge to most of the patients and their families justify the decreased hospitalization given the benign course of wound infections. Modern antimicrobial therapy that includes anaerobic coverage seems to be a major determinant in the prevention of wound infection and its morbidity in appendicitis.R.‘2s13The benefits of peritoneal drainage and intraoperative abdominal irrigation remain controversial. Some investigators suggest that drains brought through the incision in appendicitis serve largely to allow fluid egress from the wound, which might abet the wound infection rate.14 However, well-controlled studies by Haller et all5 and Greenall et al” showed no significant decrease in the complications of pediatric appendicitis when intraperitoneal drains were used. Stone et al” reports an increased incidence of septic complications resulting from transperitoneal drainage following appendectomy. The data concerning peritoneal irrigation with either saline or antibiotic solutions are conflicting. In a prospective, double-blind study, Sherman et al” saw no decrease in the rate of wound sepsis in childhood appendicitis after antibiotic peritoneal lavage. Fowler,” Smith,*’ and Sleeman et al*’ suggest that septic complications are reduced in peritonitis when antibiotic irrigation is used. Saline lavage, although not shown effective in randomized trials,22,23is widely used. Although it is difficult to compare patient cohorts at different institutions, in both the Schwartz et al’ and Karp et al9 series the wound infection rates for childhood perforated appendicitis were lower than in the present series. Their patients received triple antibiotic coverage, as did those in the present study, but both their patient groups were treated routinely with intraoperative peritoneal lavage; we rarely performed abdominal irrigation in the present patients. Perhaps this difference in operative tech-
APPENDICITIS-WOUND
CLOSURE
nique accounts for the difference in the incidence of wound infection. A final note must be made about the relationship between peritoneal culture results and the treatment of wound infections. Peritoneal cultures, which cost $43 per case, were taken in 136 patients for a total cost of $5,848 in this series. These cultures were not used to make a single therapeutic decision in the
group of children we cared for. When both peritoneal and wound cultures were positive, the infecting organism in the wound had almost always been present in the abdomen. But in all cases, antibiotic manipulation when required was based solely on growth from the wound. These data suggest that routine peritoneal culture is both unnecessary and costly and should be abandoned.
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