Interval laparoscopic appendectomy in children

BACKGROUND: Conservative management of advanced complicated appendicitis in children is becoming more common. Formation of an appendiceal mass or abscess may mitigate against urgent appendectomy during the acute stage, and conservative treatment followed by interval appendectomy has been advocated. We present our experience of interval laparoscopic appendectomy in our institution. MATERIALS AND METHODS: All children who were offered interval laparoscopic appendectomy between January 2000 and December 2004 were included. Retrospective case note analysis was performed and data collected included demographics, duration of symptoms, method of diagnosis, days of antibiotics, length of interval, operative time, length of hospital stay (conservative treatment and interval laparoscopic appendectomy), analgesia requirements, complications, and histology. RESULTS: Thirty-six children, median age 8 years (range, 1-15 years) diagnosed with appendiceal mass or abscess were offered interval laparoscopic appendectomy by two surgeons in our institution: one patient declined interval laparoscopic appendectomy. Median antibiotic treatment was 10 days (range, 3-23 days). Median length of stay for conservative treatment was 6 days (range, 1-27 days). Five children required percutaneous drainage. For the 35 children who had interval laparoscopic appendectomy, the median interval was 93 days (range, 34-156 days) and median operative time was 55 minutes (range, 25-120 minutes). Median length of stay for interval laparoscopic appendectomy was 1 day (range, 1-3 days). There were no complications following interval laparoscopic appendectomy. CONCLUSION: Interval laparoscopic appendectomy can be safely performed in children, is associated with a short hospital stay and minimal morbidity, analgesia, and scarring following conservative management of appendiceal mass or abscess. Interval laparoscopic appendectomy eliminates the risk of recurrent appendicitis and serves to excise undiagnosed carcinoid tumors. In future it may be possible to perform interval laparoscopic appendectomy as a day-case procedure in selected patients.     

Predictors of outcome for children with perforated appendicitis initially treated with non-operative management

BACKGROUND: Initial non-operative therapy for children with perforated appendicitis has become increasingly popular with the advent of powerful broad-spectrum antibiotics. However, there is no consensus regarding which patients may be managed effectively with this strategy. We reviewed all children with perforated appendicitis who were treated initially with non-operative therapy to determine those characteristics that may predict a successful outcome. METHODS: We reviewed the medical records of children admitted to our hospital between January 1, 2000 and May 1, 2003 with the diagnosis of perforated appendicitis. Only those who were treated initially with a single broad-spectrum antibiotic (piperacillin-tazobactam), with the intention of performing an interval appendectomy, were included in this study. Patients were divided into two groups based on whether they were managed successfully with non-operative therapy: Responders and non-responders. Non-responders were defined as patients who either did not improve with antibiotic therapy or who required appendectomy prior to their electively scheduled time (six weeks). Demographic data, duration and type of presenting symptoms, initial white blood cell count (WBC), percent bands, percent neutrophils (PMNs), computed tomography (CT) interpretation, and interventions/operations were abstracted. Categorical data were compared using Chi-square analysis or the Fisher exact test; continuous variables were compared using the Student t-test and the Mann-Whitney U-test. RESULTS: Overall, 26% (19/73) of patients treated initially non-operatively required appendectomy prior to the electively scheduled date. There was no difference between responders (n = 54) and non-responders (n = 19) with respect to age, gender, initial WBC, percent bands, percent PMNs, or duration and type of presenting symptoms. However, responders were more likely to have a phlegmon on CT scan compared to non-responders (11/54 vs. 0/19, p = 0.03). Non-responders were twice as likely to undergo drainage of an abscess by interventional radiology (10/19 vs. 13/54, p = 0.02) compared to responders. Among all patients who required percutaneous drainage, the failure rate of non-operative management was 43% (10/23). CONCLUSIONS: Children with perforated appendicitis can be managed effectively with nonoperative therapy, even in the presence of intra-abdominal abscesses. However, the need for abscess drainage increases the failure rate, perhaps due to inadequate source control. Those patients with a phlegmon on CT scan as opposed to an abscess, are most likely to respond to non-operative management. Initial non-operative therapy of perforated appendicitis in children is appropriate under certain clinical circumstances, especially when the body itself or interventional radiology can achieve adequate source control.     

Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial

Introduction

Perforated appendicitis is a common condition in children, which, in a small number of patients, may be complicated by a well-formed abscess. Initial nonoperative management with percutaneous drainage/aspiration of the abscess followed by intravenous antibiotics usually allows for an uneventful interval appendectomy. Although this strategy has become well accepted, there are no published data comparing initial nonoperative management (drainage/interval appendectomy) to appendectomy upon presentation with an abscess. Therefore, we conducted a randomized trial comparing these 2 management strategies.

Methods

After internal review board approval (#06 11-164), children who presented with a well-defined abdominal abscess by computed tomographic imaging were randomized on admission to laparoscopic appendectomy or intravenous antibiotics with percutaneous drainage of the abscess (when possible), followed by interval laparoscopic appendectomy approximately 10 weeks later. This was a pilot study with a sample size of 40, which was based on our recent volume of patients presenting with appendicitis and abscess.

Results

On presentation, there were no differences between the 2 groups regarding age, weight, body mass index, sex distribution, temperature, leukocyte count, number of abscesses, or greatest 2-dimensional area of abscess in the axial view. Regarding outcomes, there were no differences in length of total hospitalization, recurrent abscess rates, or overall charges. There was a trend toward a longer operating time in patients undergoing initial appendectomy (61 minutes versus 42 minutes mean, P = .06).

Conclusions

Although initial laparoscopic appendectomy trends toward a requiring longer operative time, there seems to be no advantages between these strategies in terms of total hospitalization, recurrent abscess rate, or total charges.     

Surgery for appendicitis: is it necessary?

ABSTRACT Background: Appendectomy for acute appendicitis is an effective, universally accepted procedure performed more than 300,000 times annually in the United States. It is generally believed that appendicitis progresses invariably from early inflammation to later gangrene and perforation, and that appendectomy is required for surgical source control. Although non-operative management with antibiotics of uncomplicated diverticulitis, salpingitis, and neonatal enterocolitis is now established, the non-operative management of appendicitis remains largely unexplored. Methods: Systematic review of published literature and derived expert opinion. Results: Clinical, epidemiologic, radiologic, and pathologic evidence is presented for spontaneous resolution of uncomplicated acute appendicitis. The pathogenesis of appendicitis is reviewed with specific consideration of the role of bacterial infection in the pathogenesis. Evidence is also provided documenting the clinical success of non-operative management. Conclusions: Appendectomy may not be necessary for the majority of patients with acute uncomplicated appendicitis, as many patients resolve spontaneously and others may be treatable with antibiotics alone. However, the supporting documentation is scant and of poor quality. A randomized, prospective trial of non-operative management versus early appendectomy of acute uncomplicated appendicitis corroborated by radiologic imaging is called for.     

Is acute appendicitis a surgical emergency?

Urgent appendectomy has become the basis of management for acute appendicitis because of the disparity in morbidity and mortality rates between perforated and nonperforated appendicitis. Immediate surgery results in the confirmation of diagnosis and the control of sepsis without the risk of recurrent appendicitis. However, when notified by the emergency room of the diagnosis, many surgeons are opting to begin antibiotics and intravenous fluids and to schedule the appendectomy at their convenience. We hypothesize that using intravenous antibiotics and hydration to delay appendectomy until "normal business hours" has a negative impact on patient morbidity and mortality. During a 23-month period, the medical records of 81 patients at a single institution who underwent appendectomy were reviewed. All patients had preoperative CT scans and all operations were performed by one of two surgeons. Group A included those patients who underwent appendectomy within 10 hours of CT diagnosis and group B included those appendectomies performed greater than 10 hours after diagnosis. Wound complications, antibiotic use, total analgesic requirements, length of operation, and hospital length of stay were used for comparison. The average time to operation (3.18 vs 15.85 hours), operative time (54.1 vs 55.7 minutes), length of stay (2.65 vs 2.09 days), wound infections (4 vs 0), and antibiotic use at discharge (19 vs 3) for group A and B were not statistically different. This data suggests that delaying operative intervention for acute appendicitis to accommodate a surgeon's preference or to maximize a hospital's efficiency does not pose a significant risk to the patient.     

Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis

OBJECTIVE: A systematic review of the nonsurgical treatment of patients with appendiceal abscess or phlegmon, with emphasis on the success rate, need for drainage of abscesses, risk of undetected serious disease, and need for interval appendectomy to prevent recurrence. SUMMARY BACKGROUND DATA: Patients with appendiceal abscess or phlegmon are traditionally managed by nonsurgical treatment and interval appendectomy. This practice is controversial with proponents of immediate surgery and others questioning the need for interval appendectomy. METHODS: A Medline search identified 61 studies published between January 1964 and December 2005 reporting on the results of nonsurgical treatment of appendiceal abscess or phlegmon. The results were pooled taking the potential clustering on the study-level into account. A meta-analysis of the morbidity after immediate surgery compared with that after nonsurgical treatment was performed. RESULTS: Appendiceal abscess or phlegmon is found in 3.8% (95% confidence interval (CI), 2.6-4.9) of patients with appendicitis. Nonsurgical treatment fails in 7.2% (CI: 4.0-10.5). The need for drainage of an abscess is 19.7% (CI: 11.0-28.3). Immediate surgery is associated with a higher morbidity compared with nonsurgical treatment (odds ratio, 3.3; CI: 1.9-5.6; P < 0.001). After successful nonsurgical treatment, a malignant disease is detected in 1.2% (CI: 0.6-1.7) and an important benign disease in 0.7% (CI: 0.2-11.9) during follow-up. The risk of recurrence is 7.4% (CI: 3.7-11.1). CONCLUSIONS: The results of this review of mainly retrospective studies support the practice of nonsurgical treatment without interval appendectomy in patients with appendiceal abscess or phlegmon.     

Is Interval Appendectomy Necessary for Appendicular Phlegmon? A Prospective Study

Appendectomy is accepted as the standard treatment of acute appendicitis, but in complicated cases, the treatment of choice is not straightforward. In this prospective study, we compared failure rate, complications, and recurrence rate of three different approaches to complicated appendicitis. In a 5-year prospective cohort study, patients with appendicular phlegmon were studied in three groups based on the treatment protocols. Group A included patients who underwent an appendectomy; patients of group B were treated by interval appendectomy; and in group C, conservative management was performed without interval appendectomy. Data analysis was performed using SPSS version 11.5. In total, 3896 patients with acute appendicitis were admitted, and 127 patients with complicated appendicitis were treated. Fifty-four patients were excluded from the study. Differences in age, gender, weight, and duration of symptoms were not statistically significant in the three groups. In group A (N = 23), appendectomy was impossible in 4 patients and 5 patients experienced complications. In group B (N = 24), two patients underwent exploration and appendectomy. In another two patients, a recurrent episode of acute appendicitis with mild signs and symptoms occurred after discharge from the hospital. In group C (N = 25), three patients experienced a recurrent appendicitis. Interval appendectomy is not indicated in all patients and continuous non-operative management may be appropriate in some patients. As the epidemiology of colorectal cancer and inflammatory bowel diseases is different in Iran, we recommend other researchers to perform a cost-effectiveness analysis on colon and appendicular neoplasms workup after non-operative management of complicated appendicitis.     

PILONIDAL SINUS: MANAGEMENT OBJECTIVES

In spite of a number of ingenious operative and non-operative techniques in the management of pilonidal sinus no single technique can be relied upon to prevent recurrence of this benign yet troublesome condition. Once thought to be a congenital condition it is now appreciated that pilonidal sinus is most often an acquired condition due to accumulation of tough, bristly hair penetrating the skin, or local hair growing into a skin crevice, pit or abnormal follicle. The most common site is the upper natal cleft but the condition may occur in other sites especially where there is a crevice or irregularity of skin surface with pressure or suction applied to that region. Most surgical procedures have been designed to eradicate the existing sinus and the crevice in which hair tends to accumulate. However, without the presence of hair there can be no pilonidal sinus and, in the past, little attention has been given to preventing the re-accumulation of hair in the troublesome site; hence the risk of recurrence. Management objectives should be directed not only at eradicating the obvious lesion present but also to preventing recurrence of the aetiological factors: especially the re-accumulation or re-growth of hair.     

The avoidable excesses in the management of perforated appendicitis in children

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.     

Interval appendectomy after perforated appendicitis: what are the operative risks and luminal patency rates?

BackgroundThe need for interval appendectomy after nonoperative management of a perforated appendicitis is being questioned owing to recent studies that estimated recurrence rates as low as 5% because of obliteration of the appendiceal lumen. We review our experience with interval appendectomy in this subset of patients to determine the postoperative outcomes and luminal patency rates.MethodsA retrospective review was conducted of all children treated nonoperatively for a perforated appendicitis followed by elective interval appendectomy during the past 10 years. The data collected included initial hospitalization, convalescence period, perioperative course, and luminal patency rates.ResultsA total of 128 patients were identified, of whom 55% were male. Their mean ± SD age was 9.1 ± 4.2 years. The mean interval from the initial presentation to appendectomy was 65.9 ± 20.3 d. All but 2 of the patients underwent laparoscopic appendectomy with 3 conversions to open surgery. The mean operative time was 43.6 ± 19.2 min. The complication rate was 9%, including 1 postoperative abscess, 1 reoperation for bleeding, and 1 readmission for Clostridium difficile infection. Six patients had a superficial wound infection, and 2 patients underwent outpatient procedures for suture granuloma. No risk factors for complications were identified. Of the specimens, 16% had obliterated lumens.ConclusionsMajor postoperative morbidity for interval appendectomy after a perforated appendicitis is low and should not be a deterrent in offering interval appendectomy to this subset of patients.     

Interval routine appendectomy following conservative treatment of acute appendicitis: Is it really needed

Conservative management of acute appendicitis (AA) is gradually being adopted as a valuable therapeutic choice in the treatment of selected patients with AA. This approach is based on the results of many recent studies indicating that it is a valuable and effective alternative to routine emergency appendectomy. Existing data do not support routine interval appendectomy following successful conservative management of AA; indeed, the risk of recurrence is low. Moreover, recurrences usually exhibit a milder clinical course compared to the first episode of AA. The role of routine interval appendectomy is also questioned recently, even in patients with AA complicated by plastron or localized abscess formation. Surgical judgment is required to avoid misdiagnosis when selecting a conservative approach in patients with a presumed "appendiceal" mass.     

The treatment of acute superficial abscesses: a prospective clinical trial.

A total of 219 acute superficial abscesses was treated. Patients were randomly allocated to one of four treatment groups--primary suture with or without antibiotics and free drainage with or without antibiotics. No difference could be detected between the groups in duration of healing time. Eleven per cent of all abscesses sutured recurred and antibiotics did not affect this rate. It is suggested that free drainage following incision and drainage is the safest treatment for the majority of abscesses. Antibiotics do not have any significant effect on healing time or recurrence and their routine use is not recommended.     

Interval laparoscopic appendectomy for appendicitis complicated by pylephlebitis.

BACKGROUND: Although rare, portal mesenteric venous thrombosis and pylephlebitis remain potential life-threatening sequelae of ruptured appendicitis in children. Treatment recommendations from recent reports have included urgent exploratory laparotomy with appendectomy, prolonged intravenous antibiotic therapy, and anticoagulation for up to a year. METHODS: This report describes successful management of pylephlebitis and mesenteric venous thrombosis complicating ruptured appendicitis with intravenous antibiotics and anticoagulation followed by interval laparoscopic appendectomy. RESULTS: A previously healthy 5-year-old girl was diagnosed with ruptured appendicitis complicated by pylephlebitis and mesenteric venous thrombosis at the time of presentation. She was treated with intravenous antibiotics and anticoagulated for 3 months. She subsequently underwent interval laparoscopic appendectomy. At 3-year follow-up, she is healthy without evidence of adverse sequelae. DISCUSSION: This is the first reported case of successful, minimally invasive management of ruptured appendicitis complicated by mesenteric venous thrombosis and pylephlebitis. CONCLUSION: Similar treatment of other children with this rare presentation seems reasonable.     

Acute,medical management of left sided diverticular disease

The majority of patients with acute diverticular disease will not require operative intervention. Non-operative management of acute diverticular disease begins with proper patient selection. Antibiotic therapy may not be necessary for uncomplicated disease, and a 4-day course of antibiotics for complicated disease after source control has been obtained may be sufficient. Oral feeding should be initiated as soon as feasible. Follow up colonoscopy is warranted for patients with complicated disease or CT findings concerning for malignancy, however the interval to endoscopy may not need to be as long as previously thought. Patient education regarding surgical management after recovery is essential and should center around the risk of recurrence.     

非手术治疗胰外瘘的体会:附18例报告

目的 探讨非手术治疗胰外瘘的价值。方法 回顾分析6年间18例胰外瘘患者行非手术治疗的临床资料，分别分析其发病原因、非手术患者的选择标准、非手术治疗方法，以及治疗后患者胰外瘘量的改变。结果 18例经非手术治疗后，胰液引流量逐渐减少，在1～8个月内愈合，平均愈合时间5.5个月。拔除引流后无复发。除4例患者出现胰腺假性囊肿外无其他并发症发生。结论 非手术治疗方法治疗胰外瘘可以相对减轻患者痛苦，临床可根据情况选择。     

The advancing art and science of endoscopy

Flexible endoscopy continues to advance encompassing treatment of a variety of diseases traditionally managed surgically. This review describes and evaluates many of these new endoscopic approaches with an eye toward the future. Gastroesophageal reflux disease is now treated with several endoscopic, non-operative techniques. A procedure using radiofrequency energy delivered by a peroral catheter with small needles inserted into the wall of the esophagus causes collagen deposition and ablates transient lower esophageal sphincter relaxation, both of which reduce reflux. With this treatment, >80% of patients will reduce or stop their medication for reflux. Trials involving new injectable materials show promise with a 75-80% improvement in heartburn-related quality-of-life scores and reduced medication use. Endoscopic suture and stapling devices restore the antireflux barrier with sutures that create a pleat or plication at the gastroesophageal junction. Early results indicated that 62-74% of patients had significant improvement. Long-term results are not available for any of these new techniques and there seems to be a drop off in effectiveness over time. Gastrointestinal bleeding has been more effectively managed with the recent introduction of small clips and detachable snares to control bleeding vessels. Banding and sclerotherapy for variceal bleeding has all but eliminated urgent operation for that diagnosis. In the biliary-pancreas realm, endoscopic management of pancreatic pseudocysts, stenting of pancreatic or biliary strictures and fistulae have reduced operative indications in those disease processes. Pseudocyst drainage involves creation of a transenteric communication between the pseudocyst and the stomach or duodenum. Complete cyst resolution without recurrence can be expected in 85% of patients. While endoscopic palliation of malignant biliary strictures has been accepted for years, experience with endoscopic management of iatrogenic strictures indicates that it may serve as an alternative option without surgery in many patients. Enteric stenting using metallic self-expanding stents in the esophagus, duodenum, and colon allows alleviation of obstruction without surgery for palliantation and in the colon may relieve obstruction to avoid colostomy prior to an elective resection. On the horizon stands the flexible endoscopic route to the abdominal cavity via the transgastric route and the promise of combined endoscopic-laparoscopic approaches to complex abdominal problems. General surgeons should rekindle their interest in flexible endoscopy or risk losing entire categories of disease to other specialties or to a small specialized group of endoscopic surgeons.     

Comparison of therapeutic effectiveness of percutaneous drainage with antibiotics versus antibiotics alone in the treatment of periappendiceal abscess

Background The present study was designed to compare the therapeutic effectiveness of percutaneous drainage with antibiotics versus antibiotics alone in the treatment of appendicitis complicated by periappendiceal abscess. Methods In a prospective study, 50 patients with acute appendicitis complicated by periappendiceal abscess ≥ 3 cm in size were randomly assigned to two groups. The first group received treatment with ultrasound guided-percutaneous drainage and i.v. antibiotics (ampicillin, cefuroxime, and metronidazole), and the other group received antibiotics only. Patient’s baseline characteristics, duration of hospital stay, and treatment outcome and complications were analyzed. Results Appendectomy was avoided in 16/25 patients in the drainage group and 2/25 patients in the non-drainage group during follow-up with RR of 0.39 (95% CI = 0.22–0.62; p < 0.05). One patient in the drainage group and 8 patients in the non-drainage group underwent surgery in the first month after the beginning of treatment. Eight patients in the drainage group and 15 in the non-drainage group underwent interval appendectomy. There was no statistically significant difference between the two groups regarding patient demographics, abscess size, and pretreatment clinical symptoms. Hospital stay up to the subsidence of clinical and sonographic signs was significantly shorter (p < 0.001) in the drainage group, with a mean difference of 6.4 days (95% CI = 5.0–7.9; p < 0.05). Conclusions Percutaneous drainage with antibiotics is a safe and effective way of treating acute perforated appendicitis. The recurrence rate for these patients is relatively low, and very often interval appendectomy is not required. For patients with periappendiceal abscess ≥ 3 cm in diameter, antibiotic therapy alone is insufficient and the recurrence rate is high.     

Conservative approach is feasible in the management of acute diverticulitis of the right colon

Background: Acute diverticulitis of the caecum and ascending colon is uncommon. Controversies abound as regards the optimal surgical treatment, ranging from appendectomy, diverticulectomy to right hemicolectomy. The aim of the present paper was to review treatment strategy followed by a critical appraisal. Methods: The case notes of 30 patients with acute diverticulitis of the right colon who were treated at the United Christian Hos­pital, Hong Kong from 1992 to 1998 were systematically reviewed. The data were subjected to statistical analysis. Results: The median age was 34 years, with a male:female ratio of 1:1.15. All patients presented with acute right lower abdominal pain and localized rebound tenderness. All were diagnosed preoperatively as having appendicitis. The mean duration of symptoms was 2 days (range: 1–6 days). Two treatment groups were identified. Group A (n = 16; 53%) received appendicectomy alone, while group B (n = 14; 47%) underwent diverticulectomy in addition to appendicectomy, including one patient with perforated diverticulitis. Overall, there was no procedure‐related morbidity or mortality. Both groups received a similar duration of broad‐spectrum anti­biotics. All the patients were interviewed by phone after operation to detect any recurrence of symptoms, with a median follow‐up interval of 34 months (range: 11–78 months). There was no recurrence of symptoms in group A, which received appendicectomy and antibiotics. The only difference was operative time. Conclusion: For non‐perforated diverticulitis of the right colon, appendicectomy and intravenous antibiotics without diverticulectomy is the preferred treatment strategy.     

Is delayed operative treatment worth the trouble with perforated appendicitis is children?

BACKGROUND: Approximately 30% to 50% of appendicitis in children is already perforated at presentation. The optimal management of these children remains controversial. METHODS: Ninety-six children (aged 2 to 16 years) were treated for perforated appendicitis. Seventy-one underwent immediate appendectomy and drainage of abscess, if present (group I). In the other 25 an attempt was made to treat with intravenous antibiotics, combined with transrectal (4) or percutaneous (2) drainage of abscess. This treatment was successful in 16 patients (group II), who underwent appendectomy 6 to 8 weeks later, and unsuccessful in 9 patients (group III), who underwent appendectomy 3 to 12 days later. RESULTS: The mean length of stay was as follows: group I, 6.7 days; group II, 8.9 days; and group III, 10.9 days (not significant). The white blood cell count (WBC) at presentation was group I, 18.6 K; group II, 17.9 K; group III, 18.8 K. The percent fall of WBC on day 4 was group I, 55%; group II, 25.5%; group III, 17% (P >0.05 versus groups I and II). Twenty of 71 patients in group I (28%) developed wound infection (5), pelvic abscess (14), and pancreatitis (1), while 2 of 16 (12.5%) of group II and 1 of 9 (11%) of group III patients required readmission (both P <0.05 versus group I). CONCLUSIONS: These data show that initial antibiotic treatment of perforated appendicitis in children, followed by interval appendectomy, is useful for a select group who present with little or no peritonitis, slightly elevated temperature, and WBC that falls at least 25% within 3 to 4 days.     

MANAGEMENT OF TRANSECTED PANCREAS IN CHILDREN

The pancreas is the fourth most commonly injured intra-abdominal organ in children who sustain blunt abdominal trauma. Appropriate management of the injured pancreas has been controversial. With the advent of the computerized tomography scan, paediatric surgeons have tended to manage pancreatic injuries non-operatively. However. if pseudocysts develop. non-operative management may necessarily entail a long hospital course involving total parenleral nutrition. drainage procedures and attendant morbidity. The critical element in planning therapy is to determine the status of the pancreatic duct. We have recently encountered five children who suffered blunt pancreatic injury where the main pancreatic duct was determined to have been transected. These children underwent spleen preserving distal pancreatectomy with resultant shorter hospital stays and minimal long-term morbidity. We suggest that in children with pancreatic injury where the main pancreatic duct has been transected early operative management rather than non-operative therapy is the procedure of choice. Endoscopic retrograde cholangiopancreatography should be used to determine the status of the pancreatic duct. This modality can be both diagnostic and therapeutic in appropriate circumstances.