HIV-positive African children with rectal fistulae

Background/Purpose: Human immunodeficiency virus (HIV) disease is an increasingly common infection in children in sub-Sahara Africa. Rectal fistulation is one such condition with which these patients present to the paediatric surgeon. This appeared to be an exclusively female condition until 2 male patients were treated recently. Methods: A 6-year (1996 through 2001) retrospective study found 39 children presenting with HIV-related rectal fistulae. Thirty-seven girls were seen with rectovaginal fistulae (RVF), and there is supportive documentation showing an increase in this condition throughout Southern Africa. Until now, boys have not been described with this condition. The author presents 2 boys who complete this spectrum of HIV-related acquired rectal fistulae. Results: All patients were found to have rectal fistula at the dentate line. In girls it varied in size from pin-point to 5 mm diameter, tracking anteriorly into the vagina. When closure of the fistula was attempted, it broke down. The 2 boys had a large fistula, which tracked to the prostatic urethra on the right of the verumontanum. The first patient underwent a successful repair. The second patient had a [ldquo ]Y[rdquo ]-shaped fistula based at the dentate line, with the second limb passing into the bladder. The parents refused further treatment and took the child home. Conclusions: HIV disease affects increasing numbers of children. A spectrum of rectal fistulae now has been seen in both girls and boys. These acquired rectal fistulae arise at the dentate line in both genders. Girls with these fistulae are seen more commonly, presenting with RVF. The closure of a fistula has only been successful in one boy. J Pediatr Surg 38:62-64.     

Prospective to a randomized double-blind controlled trial to assess efficacy of double caudal analgesia in hypospadias repair

Background/Purpose: A prospective, randomised, double-blind, controlled trial to evaluate efficacy of double-caudal versus single-caudal injection for postoperative analgesia in hypospadias repair was performed. Methods: Between October 1998 and September 2000, 160 boys underwent distal hypospadias repair. The first 80 boys were analyzed prospectively for postoperative analgesia after double-caudal bupivacaine, which involves the administration of a second bupivacaine injection into the caudal extradural space at the end of surgery. Pain was assessed using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). The study groups were: group 1, unstented Thiersch-Duplay urethroplasty (50); and group 2, stented Mathieu type repair (30). Results of this cohort formed the basis for a prospective, randomised, double-blind control trial comparing double-caudal against a single injection before operation. The further 80 patients were allocated randomly: group 3, single caudal injection of 1 mL kg^{[minus ]1} of 0.25% plain bupivacaine at the start of surgery with unstented Thiersh-Duplay repair (25); group 4, similar single caudal injection but stented Mattieu type operation (15); group 5, second caudal and at end of operation (0.5 mL kg^{[minus ]1} on each occasion) with unstented Thiersh-Duplay repair (25); and group 6, similar to group 5 but with stented Mattieu type repair (15). Results: Patient demographics (age and weight) and mean duration of operative time were similar for all groups. There was no significant difference in early pain scores at 0 to 2 hours with a good correlation coefficient (r = 0.88). At 4, 6, and 8 hours there was a significant difference in pain scores between double and single caudals (P [lt ] .05). There was a significant difference in mean duration of caudal analgesia and need for oral analgesia between single caudal 3.45 versus 7.85 hours for double caudal (P [lt ] .001). Mean duration of caudal analgesia and requirement for oral analgesia after single caudal in group 3 (unstented) was 3.5 versus 3.4 hours in group 4 (stented). In double caudals this lengthened to 9.4 hours in group 5 (unstented) versus 6.3 hours in group 6 (stented; P [lt ] .05). This also was significant when operation time was excluded. Conclusions: A prospective study of double caudal analgesia showed good postoperative pain control after hypospadias surgery. This was followed by a prospective, randomised, double-blind controlled trial that has confirmed that double caudal injection of bupivacaine prolonged the duration of pain relief after hypospadias repair. The second or top-up caudal did not increase the total dose but supplemented and prolonged postoperative analgesia.     

Correction of congenital chordee penis by 'ventral separation and outward rotation of corpora'

Background/Purpose: The formation of congenital chordee penis in patients with or without hypospadias is multifactorial and not completely clear. In most cases, after release of all known causes of chordee, [ldquo ]residual[rdquo ] penile curvature can persist. The authors discuss the etiopathogenetic mechanisms of congenital chordee penis and describe their experience in surgical correction of [ldquo ]residual[rdquo ] penile curvature by [ldquo ]ventral separation and outward rotation of corpora.[rdquo ] Methods: In 22 patients with congenital chordee penis with or without hypospadias, [ldquo ]residual[rdquo ] penile curvature was corrected by [ldquo ]ventral separation and outward rotation of corpora.[rdquo ] Results: Ventral separation and outward rotation of corpora resulted in satisfactory correction of penile curvature. In only 2 cases of chordee penis without hypospadias was further intervention necessary: a Nesbit's plication was carried out in one and a neourethra placed in the other. At follow-up no residual penile curvature was observed. Conclusions: An arrest of development of the penis caused by failure of outward ventral rotation of the corpora, may contribute to the formation of chordee penis. When [ldquo ]residual[rdquo ] penile curvature persists, [ldquo ]ventral separation and outward rotation of corpora[rdquo ] can be used to correct this complex malformation. J Pediatr Surg 37:1347-1350.     

Translevator anal anomalies with cutaneous fistulae passing deep to the scrotum

Methods: The authors present a series of 9 patients collected from 4 centers with translevator anal anomalies, each of which has a fistula tracking forward deep to the scrotum and opening at the peno-scrotal junction. Whereas some would appear to be covered ani in type, others are deeper and would appear to fit in with an intermediate type of classification emphasizing the idea of a [ldquo ]spectrum[rdquo ] of malformation. Results: The anatomic arrangement, associated anomalies (eg, 2 had hypospadias), and surgical management is described briefly in each case. Careful examination may be necessary to identify the fistula. Conclusions: It is recommended that the surgery be individualized depending on the findings. On a theoretical embryologic basis there is abnormality in the formation of the outer genital folds, and there also may be abnormality in some cases of the inner genital folds. J Pediatr Surg 37:1326-1329.     

Intraoperative endosonography enhances laparoscopy-assisted colon pull-through for high imperforate anus

Purpose: The authors used ultrasonographic endoprobes during laparoscopy-assisted colon pull-through (LACPT) for the repair of high imperforate anus to confirm the pull-through canal was surrounded symmetrically by pelvic floor muscles. Methods: Six patients with high imperforate anus were treated by LACPT (mean age at LACPT, 8.2 months). An endoscopic (12-MHz, 2.5-mm in diameter) and proctoscopic (7.5-MHz, 12-mm in diameter) probe were inserted into the proposed route of dissection intraoperatively to measure the thickness of the surrounding muscle tissue at at least 3 levels: the external anal sphincter, the levator ani muscle sling, and the intervening muscle complex. Results: The average thickness of the external anal sphincter was 2.3 [plusmn] 0.4 mm anteriorly, 2.4 [plusmn] 0.4 mm on the left, 2.4 [plusmn] 0.5 mm posteriorly, and 2.6 [plusmn] 0.6 mm on the right. The average thickness of the muscle complex was 2.3 [plusmn] 0.6 mm anteriorly, 2.2 [plusmn] 0.5 mm on the left, 2.1 [plusmn] 0.4 mm posteriorly, and 2.2 [plusmn] 0.5 mm on the right. The average thickness of the left crus of the levator ani muscle was 1.8 [plusmn] 0.3 mm, the right crus was 1.9 [plusmn] 0.4 mm, and the rim located posterior to the rectum was 2.0 [plusmn] 0.3 mm. No statistically significant difference was found between the measurements taken at each level. Conclusion: Intraoperative endosonography during LACPT can greatly enhance the precision of positioning the pull-through canal.     

The Dartos Flap as an Adjunct in Preventing Urethrocutaneous Fistulas in Repeat Hypospadias Surgery

Purpose

Vascularized flaps for repeat hypospadias repair are often limited. We report our experience with the dartos flap in children undergoing secondary hypospadias and complex urethral repair.

Materials and Methods

The dartos flap is fibroadipose tissue between the scrotal skin and tunica vaginalis layers with its vascular pedicle based at the penoscrotal angle. The flap reaches the distal penile shaft without tension. Eight patients 1 to 17 years old (mean age 6) underwent urethral surgery and an interposed dartos flap procedure in 1994 to 1995.

Results

Of 6 patients cosmesis was excellent in 84 percent, erections were straight in 100 percent, and urinary streams were of good quality and without fistula in 100 percent after repeat hypospadias surgery. Following staged repair for anterior urethral valves a urethrocutaneous fistula developed in 1 patient and following urethral duplication repair results were excellent in 1. Mean followup was 1 year.

Conclusions

The dartos flap is easy to mobilize and it provides excellent coverage for repeat proximal hypospadias surgery, since the dartos remains undisturbed. We endorse its use for complex urethral surgery and believe that the extra layer of closure helps to prevent urethrocutaneous fistulas.     

Feasibility of thoracoscopic repair of esophageal atresia with distal fistula

Backgound/Purpose: Evaluation of the feasibility of thoracoscopic correction of esophageal atresia with distal fistula. Methods: Eight consecutive neonates with esophageal atresia and distal fistula were treated thoracoscopically. Mean birth weight was 3,048 g (range, 2,140 to 3,770). The patients were intubated endotracheally and placed in a [frac34] left prone position. Three cannulae were inserted along the inferior tip of the scapula. CO₂ was insufflated at a pressure of 5mm Hg and a flow of 0.5 L/min. The fistula was either clipped or ligated. The proximal esophagus was opened and an anastomosis was made over a 6F or 8F nasogastric tube with interrupted 5-0 Vicryl. Results: All procedures were completed thoracoscopically without major peroperative complications. The mean operating time was 198 minutes (range, 138 to 250). One patient had a major leak, resulting in a stormy postoperative course, but the leak healed on conservative treatment. This patient and 3 others had stenosis requiring dilatation, respectively, 3, 6, 12, and 1 times. The babies were fed after a median period of 8 days. The median hospital stay was 13 days. Conclusions: Thoracoscopic repair of esophageal atresia with distal fistula is feasible. Larger series are needed to determine the exact place of the thoracoscopic approach.     

Biliary atresia,the next generation: a review of liver function,social activity,and sexual development in the late postoperative period

Purpose: The current study aimed to establish the management for biliary atresia (BA) patients in the late postoperative period. Methods: Of 165 BA patients operated on in the authors' department, 44 patients (16 boys, 28 girls) with a follow-up period of more than 15 years were reviewed retrospectively. Results: Forty-one of 44 patients (93.2%) currently are employed or highly educated, 7 are married, whereas 2 (4.5%) died, and 10 (22.7%) required liver transplantation after puberty. Four babies have been born from BA parents without congenital anomalies. Four girls conceived 5 times and delivered 3 newborns weighing 2,330 to 2,474 g including one delivered after transplantation. Maternal portal hypertension uniformly deteriorated during pregnancy, and one pregnancy was terminated. Menstrual disorder correlated significantly with the biochemical data related to liver function at puberty such as serum choline esterase (266 [plusmn] 70.4 in 19 normal patients v 159 [plusmn] 34.3 IU/L in 9 abnormal patients, P = .00057), asparate aminotransferase (42 [plusmn] 30.8 v 96.0 [plusmn] 63.6 IU/L; P = .0031), and serum albumin (4.6 [plusmn] 0.4 v 3.9 [plusmn] 0.6 g/dL; P = .013). Conclusions: The long-term survivors of Kasai's operation, with or without liver transplantation, have reached the next generation. Transgenerational follow-up and management including conception and perinatal care should be required for BA patients.     

Transverse preputial onlay island flap urethroplasty for single-stage correction of proximal hypospadias

Aims and objectives

Transverse preputial onlay island flap urethroplasty (TPOIF) was described initially for distal hypospadias, but has seen extended application for proximal hypospadias. We describe a set of modifications in the technique and results in a large series of proximal hypospadias.

Materials and methods

All children who underwent TPOIF repair for proximal hypospadias (proximal penile, penoscrotal and scrotal) from June 2006 to June 2013 by a single surgeon were prospectively followed till June, 2014. A standard technique and postoperative protocol were followed. Salient points to be emphasized in the technique: (1) dissection of the dartos pedicle till penopubic junction to prevent penile torsion, (2) incorporation of the spongiosum in the urethroplasty, (3) midline urethral plate incision in glans (hinging the plate), (4) Dartos blanket cover on whole urethroplasty.

Results

Out of 136 children with proximal hypospadias, 92 children who underwent TPOIF formed the study group. Out of 92 children, 48 (52 %) children required a tunica albuginea plication for chordee correction. In total, 16 (17 %) patients developed 24 complications and 11 children (12 %) required second surgeries: fistula closure in 7 (with meatoplasty in 5), glansplasty for glans dehiscence in 2 and excision of diverticulum in 2. Two children required a third surgery. Only 5 children had a noticeable penile torsion (less than 30 degree), and 7 had a patulous meatus.

Conclusions

Transverse preputial onlay island flap urethroplasty can deliver reliable cosmetic and functional outcomes in proximal hypospadias.

     

Surgical management of open versus laparoscopic adrenalectomy: outcome analysis

Purpose: The authors sought to compare the outcome of children undergoing open versus laparoscopic adrenalectomy for an adrenal tumor. Methods: Medical records of children that underwent an adrenalectomy from 1990 through 1999 were reviewed. Sixty-four adrenalectomies were performed: 27 pheochromocytomas, 36 neuroblastomas, and 1 virilizing tumor. Sixty adrenalectomies were performed open and 4 laparoscopically. The patient's age, surgical length of stay, operative charge, hospital cost, operating time, blood loss, and outcome were examined. Results: Mean age for an open procedure was 8.9 [plusmn] 0.9 years and 14 [plusmn] 1.1 for laparoscopic (P = .019). Surgical length of stay for open was 5.4 [plusmn] .38 days and 2.7 [plusmn] .62 days for laparoscopic (P = .006). Patient operative charges were $12,941 [plusmn] 676 for laparoscopic and $4,714 [plusmn] 411 for open (P [lt ] .001). When total estimated patient cost, including hospital stay, were compared between groups there was no significant difference. Similar mean operating times and blood loss were noted. There were no deaths or complications in children with a pheochromocytoma. The mortality rate in children with neuroblastoma was 28%. Conclusions: Adrenalectomy for benign tumors can be performed safely. In selected children a laparoscopic procedure can be expected to decrease the surgical length of stay without increasing operating time or complications. J Pediatr Surg 37:1027-1029.     

The use of pedicled appendix graft for substitution of urethra in recurrent urethral stricture

Background: Recurrent posterior urethral strictures after failed urethroplasty may need urethral substitution. Skin or mucosal grafts, currently used for this purpose, have a high complication rate. The authors describe the use of pedicled appendix for posterior urethral substitution. Methods: Two boys with pelvic fracture urethral distraction injuries were treated for recurrent posterior urethral strictures after a failed perineal anastomotic urethroplasty. Through a perineal-transpubic approach the stricture tissue was excised, which resulted in a gap of 5 to 7 cm between the healthy ends. The vermiform appendix was mobilised on its own pedicle and transposed to the perineum; the proximal end of appendix was anastomosed to the prostatic urethra and the distal end (tip discarded) to the bulbar/penile urethra. Omentum was transposed to wrap the anastomosis and fill the dead space. Results: Normal micturition was restored in both patients. No further treatment was required after 1 dilatation in the first case. Both patients are continent. Potency status remains unchanged from the preoperative period with normal erections in 1 case. Follow-up (1 to 3 years) has been satisfactory with no complications. Conclusions: The appendix is a promising organ for posterior urethral replacement. It can be brought to the perineum on its own vascular pedicle.     

Small bowel allografts maintained by administration of bombesin while under immunosuppression

Background/Purpose: The aim of this study was to determine if Bombesin (BBS) could help maintain the mucosal villus state in small bowel allografts without inducing acute rejection under immunosuppression. Methods: Allogeneic small bowel transplantation was performed heterotopically in rats (n = 12). All rats received daily administration of FK506 from postoperative day 0 to day 28. On postoperative day 14, rats were divided into 2 groups of 6 rats each, and administered BBS or normal saline as a control. After 2 weeks of treatment, the rats were killed, and the graft mucosal villus state was evaluated by H[amp ]E staining, and crypt cell proliferation analysis was performed using immunohistochemistry with proliferative cell nuclear antigen (PCNA). Results: Villi were thin, and villus blunting was marked in the control group. The BBS group showed that the villi of the grafts were well maintained, and the volume of the lamina propria mucosa was adequately preserved. The PCNA labeling index of crypt cells in the control group was 40.06 [plusmn] 3.36 (mean [plusmn] SD) and that in the BBS group was 61.02 [plusmn] 4.27. There was a significant difference (P [lt ] .001) between the 2 groups. Conclusions: BBS maintained allograft epithelial cells and the volume of the lamina propria intestinal mucosa, stimulating proliferation of crypt cells under immunosuppression without inducing acute rejection. J Pediatr Surg 38:83-87.     

Role of plasma thrombopoietin level in thrombocytopenia of postoperative biliary atresia patients

Background/Purpose: To evaluate if thrombocytopenia may be related to plasma thrombopoietin level (P-TPO) in postoperative biliary atresia (BA). Methods: Forty-three postoperative BA patients aged 1 to 20 years were included. P-TPO was measured by enzyme immunoassay. P-TPO was compared with platelet counts (Plt), Child's classification, presence of splenomegaly, and liver function tests. Results: P-TPO significantly correlated with Plt, child's classification, serum albumin, and cholinesterase level, respectively. In 4 patients undergoing portal decompression procedure, preoperative and postoperative Plt and P-TPO were 87.5 [plusmn] 69.1 [times ] 10³ and 50.3 [plusmn] 28.0, 118.8 [plusmn] 62.3 [times ] 10³/mm³, and 53.0 [plusmn] 55.0 pg/mL, respectively, without significant difference. In 6 patients undergoing liver transplantation (LTx), Plt and P-TPO after LTx was 157.5 [plusmn] 83.5 [times ] 10³ and 143.5 [plusmn] 75.2, respectively, which were significantly higher than those before LTx (55.0 [plusmn] 15.6 [times ] 10³/mm³ and 53.2 [plusmn] 32.9 pg/mL). Conclusion: Thrombocytopenia in postoperative BA may be caused by decreased plasma TPO level in accordance with the severity of liver dysfunction rather than hypersplenism. J Pediatr Surg 37:1195-1199.     

Stooling and manometric findings after primary pull-throughs in Hirschsprung's disease: Perineal versus abdominal approaches

Background/Purpose: Primary pull-through via a perineal approach (PA) has recently been reported for Hirschsprung's disease. One criticism of this approach is that it requires a large amount of retraction on the anal sphincters. Additionally, because the procedure is new, most patients undergoing a PA are too young to assess long-term continence rates. This study examined early stooling patterns, anal sphincteric pressures, and number of enterocolitic episodes in infants who underwent a PA. Results were compared with a conventional combined transabdominal and perineal approach (TA). Methods: Over 2 years, 26 pull-through procedures were performed. Nine of those were PA, and 17 were TA. Twelve of the 26 patients had formal manometric studies postoperatively. Results are expressed as mean [plusmn] SD; unpaired t test and [Chi ]² were used for statistical analysis. Results: Mean follow-up post[ndash ]pull-through was 23 [plusmn] 2.3 months for the TA and 14 [plusmn] 1.9 months for the PA. Manometric resting sphincter pressure in the TA group averaged 79 [plusmn] 17 mm Hg compared with 76 [plusmn] 21 mm Hg in the PA group (P = .78). Number of stools per day was 3.3 [plusmn] 0.6 in the TA group compared with 2.2 [plusmn] 0.3 in the PA group (P = .17). Post[ndash ]pull-through enterocolitis was experienced by 53% of the TA group (mean, 1.5 [plusmn] 0.6 episodes) and 56% of the PA group (mean 0.9 [plusmn] 0.4 episodes) for a P = .08 by [Chi ]² analysis. Conclusions: Manometric sphincter pressure and enterocolitic episodes after a PA for Hirschsprung's disease appear to be similar to results obtained with a conventional TA. Evaluation of early stooling frequency shows a comparable frequency after a PA. This suggests that both methods are safe, and the PA does not appear to compromise sphincter integrity. J Pediatr Surg 37:1321-1325.     

Evaluation of the location of the anus by a modified technique in the neonate

Purpose: The aim of the current study was to bring to notice the anterior displacement of the anus and to recommend the measurement of anal position index in the neonate by a modified method. Methods: Sixty newborns (34 girls and 26 boys) were taken into study, and the anal position index (API), which is the ratio of anus-fourchette (scrotum) distance to coccyx fourchette (scrotum) distance, was measured. To obtain the measurement, a transparent adhesive tape was placed along the midline on the long axis, covering the anus. The upper and lower tips and the center of the anal circle was marked and measured using a caliber. Results: API was found as 0.46 (SD [plusmn] 0.08) and 0.53 (SD [plusmn] 0.05) in female and male neonates, respectively. Because an index of 0.34 in girls and 0.46 in boys are considered abnormal, the 3 female babies in the study group with API indices of 0.18, 0.28, and 0.33 were subjected to further examination. The abnormality was seen not to be rare in the Aegean region. Conclusions: An abnormal index alone cannot be the sole cause of constipation mentioned in the literature and therefore not an indication for operation. Anal position index in the neonates could be measured more accurately by the current modified method. If an anterior location of the anus is found early in infancy the baby should undergo follow-up accordingly.     

Ad libitum feeding decreases hospital stay for neonates after pyloromyotomy

Purpose: The optimal feeding regimen for neonates after pyloromyotomy for hypertrophic pyloric stenosis (HPS) remains controversial. This study sought to compare ad libitum feeding to a Conventional feeding regimen with regard to time to full diet, length of hospital stay, and readmission rates. Methods: A 6-month review of 36 consecutive patients who underwent pyloromyotomy for HPS was undertaken. Patients were fed in 1 of 2 ways according to specific surgeon preference. Conventional Regimen patients (n = 19) were kept nothing by mouth (NPO) for 6 hours after surgery and incrementally advanced to full feedings. ad libitum (n = 17) patients were kept NPO until fully reversed from anesthesia and then given full strength formula or breast milk. Discharge was considered when 2 feedings of 60 mL were tolerated. Results: Twenty-eight males and 8 females with a mean age of 5.0 [plusmn] 1.7 (SD) weeks, gestational age of 39 [plusmn] 2.1 weeks, weight of 4.0 [plusmn] 0.9 kg, and operating time of 56 [plusmn] 12 minutes were studied. The interval from operating room to full diet was significantly less with ad libitum feeding than on the conventional regimen (20.3 [plusmn] 5.0 v. 25.4 [plusmn] 8.3 hours, P [lt ] .05). The Ad Libitum group also had a significantly decreased length of hospital stay (28.5 [plusmn] 8.9 hours v. 35.8 [plusmn] 11 hours; P [lt ] .05). There were no readmissions in either group. Conclusions: Ad libitum feedings decrease time to full diet and discharge without an increase in readmission rates. The estimated potential savings per patient using ad libitum feedings were $392.00. Thus, the use of ad libitum feedings after pyloromyotomy for HPS appears indicated.     

Epidermal growth factor improves nutritional outcome in a rat model of short bowel syndrome

Background/Purpose: This study investigates the effect of epidermal growth factor (EGF) on nutrient absorption in a rat model of short bowel syndrome (SBS). Methods: Male juvenile rats underwent either transection (Sham) or ileocecal resection leaving a 20-cm jejunal remnant. Animals underwent follow-up for 10 days, and resected animals were treated with placebo or recombinant human EGF (1-53). Animals were pair fed; in vivo nutrient absorption, intestinal permeability, morphology, and total intestinal DNA and protein content were measured. Results: Resected EGF-treated animals lost significantly less weight than those in the placebo group ([minus ]4.2 [plusmn] 3 v [minus ]13.7 [plusmn] 6.9%), absorbed significantly more 3-0 methylglucose (76.8 [plusmn] 6.6 v 64.9 [plusmn] 10.1%), and had reduced permeability (lactulose/mannitol ratio, 0.35 [plusmn] 0.19 v 0.60 [plusmn] 0.20; P [lt ] .05 for all comparisons). Conclusions: These findings show that treatment of short bowel syndrome animals with EGF reduced weight loss and improved carbohydrate absorption and intestinal permeability. These findings suggest that enteral EGF may be a useful therapy for short bowel syndrome; further studies are indicated.     

Prospective evaluation of nonsurgical versus surgical management of appendiceal mass

Purpose: Prospective evaluation was undertaken of surgical findings, complications, morbidity, and hospital stay between initial nonsurgical management versus early surgical intervention of an appendicular mass. Methods: A prospective, nonrandomized study was conducted of 82 consecutive patients (mean age, 6.9 [plusmn] 3.3 years) presenting with an appendicular mass over a 5-year period. They were categorized as group 1, 58.5% (48 of 82) nonsurgically managed and an interval appendectomy performed at a mean period of 8.6 [plusmn] 4.6 weeks and group 2, 41.5% (34 of 82) appendectomy at presentation. Results: An appendix was identified in all 82 patients in both groups at operation. In-group 1, recurrent episodes of abdominal pain necessitated interval appendectomy in 39.6% (19 of 48) patients at a mean 4.3 [plusmn] 0.8 versus 11.5 [plusmn] 3.7 weeks in 60.4% (29 of 48) who underwent scheduled interval appendectomy. Periappendiceal abscesses present at interval appendectomy in group 1 was (38 of 48) 79.2% versus 100% (34 of 34) at appendectomy in group 2. Adhesions at interval appendectomy in group 1 was 81.3% (39 of 48) versus 100% (34 of 34) at appendectomy in group 2. In-group 1, superficial wound infection was observed in 0 versus 4 wound infections in group 2. Overall morbidity rate between group 1 and group 2 was statistically significant (P [lt ] .05). Total mean hospital stay in group 1 was 13.2 [plusmn] 1.5 versus 4.8 [plusmn] 0.4 days in group 2. Of the 48-interval appendectomy specimens, 37 of 48 (77%) appendices had a patent lumen, and 11 of 48 (23%) showed fibrosis and obliteration of appendicular lumen. There was no correlation (r = 0.22) between the histopathologic findings and the interval between abscess treatment and interval appendectomy. Conclusions: Early surgical intervention was beneficial over nonoperative management in this cohort of patients. Interval appendectomy is recommended after nonsurgical management of an appendicular mass. J Pediatr Surg 37:882-886.